Egypt's Other Wars: Epidemics and the Politics of Public Health

By Nancy Elizabeth Gallagher

Three devastating epidemics swept Egypt in the 1940’s killing more people than all the wars Egypt has fought in the twentieth century. Egypt’s Other Wars vividly reconstructs the nation’s struggle against malaria, relapsing fever, and cholera and explores the unique combination of forces that put public health at the top of the national political agenda.

Egypt in the 1940’s as in the throes of a nationalist upheaval. Nationalists of all political ideologies attributed the sever epidemics that the country was experiencing to Egypt’s status as an underdeveloped and colonized nation. The epidemics were therefore viewed for the first time as not only a public health crisis but also a political problem that called for a political solution.

• Language: English
• Publisher: Syracuse University Press
• Release date: Oct 29, 2021
• ISBN: 9780815655527

Book preview

Egypt’s Other Wars

Contemporary Issues in the Middle East

Volunteer interviews the sick in Luxor, 1944. Painting by Amina Sidqi.

Egypt’s Other Wars

Epidemics and the Politics of Public Health

Nancy Elizabeth Gallagher

Syracuse University Press

Copyright © 1990 by Syracuse University Press

Syracuse, New York 13244-5290

All Rights Reserved

First Paperback Edition 2021

21  22  23  24  25  266  5  4  3  2  1

∞ The paper used in this publication meets the minimum requirements of the American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1992.

For a listing of books published and distributed by Syracuse University Press, visit https://press.syr.edu.

ISBN: 978-0-8156-2766-1 (paperback)

978-0-8156-2507-0 (hardcover)

978-0-8156-5552-7 (ebook)

Library of Congress has cataloged the hardcover edition as follows:

Gallagher, Nancy Elizabeth, 1942–

Egypt’s other wars : epidemics and the politics of public health / Nancy Elizabeth Gallager. —1st ed.

p. cm.—(Contemporary issues in the Middle East)

Includes bibliographical references

ISBN 0-8156-2507-3

1. Epidemiology—Egypt—History.2. Medical policy—Egypt—History.3. Public health—Egypt—History.I. Title.II. Series

RA650.8.E3G351990

Manufactured in the United States of America

Contents

Illustrations

Acknowledgments

Abbreviations and Locations of Manuscript Sources

Textual Note

1Introduction

2Malaria Invades

3Elite Women and King Faruq to the Rescue

4Malaria in Politics

5Enter the Rockefeller Foundation

6British-American Rivalries

7Cholera Goes out of Control

8The British Connection

9Public Health on the National Agenda

10Conclusion

Notes

Bibliography

Index

Illustrations

Figures

Volunteer interviews the sick in Luxor, 1944. Painting by Amina Sidqi.

1.Muhyi al-Din Farid and a leader of the Bashariya searching for Anopheles gambiae larvae near Aswan.

2.Safiyya Zaghlul and Nahid Sirri inspecting galabiyas being prepared for shipment to Upper Egypt.

3.Ahmad Hamza with members of the Red Crescent at soup kitchen in Isna, February 1944.

4.Red Crescent members receiving blankets from the U.S. Air Force.

5.Hitler as they saw him.

6.Policeman speaks to one of the poor in Aswan.

7.A lower-class war profiteer, a foreign entrepreneur, and an effendi.

8.Ibn al-balad shaking fist at egg called Poverty.

9.The malaria mosquito is named heroine of 1944.

10.Ibn al-balad points to an airplane hangar named Poverty.

11.Masri Effendi speaks to Wakil on his departure to the United States.

12.Wadud Fayzi Musa making rounds during fever epidemic.

13.Volunteer women disinfecting a fellahin woman with DDT.

14.Volunter woman disinfecting clothing with DDT.

15.A street in al-Qurayn, August 1983.

16.The prime minister in al-Qurayn.

17.Fighting cholera in al-Qurayn.

18.A vendor pushing his cart full of cabbages into Cairo.

19.Nagib Iskandar, the minister of health, and volunteers.

20.The man who left his shadow behind him.

21.A British fly (a caricature of Mustafa Nahhas) rooting in a British army dump.

22.A British chicken has laid three eggs.

23.Masri Effendi beset with four evil spirits.

Map

Egypt, 1940s.

Acknowledgments

The help of many colleagues made writing this book a pleasure. Galal Amin, Raymond Baker, Ali al-Din Hilal Dessouki, Albert Hourani, James Jankowski, Ibrahim Karawan, Kenneth Manning, Afaf Lutfi al-Sayyid Marsot, and Earl L. Sullivan read all or part of the text at different stages and offered useful insights and suggestions. Ralph Jaeckel’s scholarly counsel was especially helpful from beginning to end. I would like to thank these and other colleagues who helped directly or indirectly with the manuscript. Any shortcomings are, of course, my own.

While researching the topic I was able to locate many people who had lived through the events under consideration. Many participated in them. I would especially like to thank the following persons: Salah Atiyya, Izdihar Abul Ala Abaza, Layla Barakat, Layla Doss, Muhyi al-Din Farid, Gertrude and Mirit Butrus Ghali, Harry Hoogstraal, Wadud Fayzi Musa, Abd al-Azim Ramadan, Adil Sabit, Fatima Shahin Sabit, and Abd al-Aziz Salah. All shared with me their memories, knowledge, and sometimes their private papers, photographs, and newspaper clippings of the 1940s. It is a privilege to acknowledge their kindness and generosity.

I would like to thank cordially Dunning Wilson and the other librarians and archivists in Egypt, Britain, and the United States who skillfully located numerous primary and secondary materials. They are the unsung heroes of academic research.

Cynthia Maude-Gembler of Syracuse University Press proved an excellent editor. Terresa Ruggieri Joseph and Kathryn Koldehoff carefully copy edited the manuscript.

The cover is a painting by Amina Sidqi done at Luxor in 1944. It depicts a volunteer from the Mabarra Muhammad Ali making a survey of the needs of impoverished malaria victims. I would like to thank Izdihar Abul Ala Abaza and the Zulficar family of Zamalek for the photographic reproduction.

I am grateful to the American Research Center in Egypt, the Social Science Research Council, the Rockefeller Foundation Archive Center, and the Academic Senate of the University of California, Santa Barbara, for funding this study. I would like to dedicate this book to my husband, Tony, and to our daughter, Lisa Marisol.

Abbreviations and Locations of Manuscript Sources

Nancy Elizabeth Gallagher, Associate Professor of History at the University of California, Santa Barbara, is the author of Medicine and Power in Tunisia, 1780–1900. After completing her work for an undergraduate degree in public health at the University of California, Berkeley, she earned a doctorate in Middle East history at the University of California, Los Angeles.

Textual Note

To make the story readable, I have intentionally kept transliteration simple and technical terms to a minimum. In most cases I have used the spelling of Webster’s Third New International Dictionary (e.g., fellah rather than fallah, tarboosh rather than tarbush). If an Arabic term is not found there, I have followed a simplified version of the transliteration system recommended by the International Journal of Middle East Studies, modifying the spelling to reflect Egyptian pronunciation (e.g., Ebeid rather than ‘Ubayd, Abaza rather than Abadha, Gamal rather than Jamal). When possible I have eliminated ‘ayns and hamzas (e.g., Muhammad Ali rather than Muhammad ‘Ali). I have omitted titles—pasha, bey, hanim, lord, and sir—in all but a few cases.

In 1946 one Egyptian pound (£E) equaled $4.13. One feddan equals 1.038 acres. One ukka equals 1.248 kg.

For those unfamiliar with Egyptian geography, Upper Egypt means the southern part and Lower Egypt means the northern part of the country. The Nile flows from south to north, so traveling downriver means traveling north.

Contemporary Issues in the Middle East

Editorial Advisory Board

Roger Allen, University of Pennsylvania

John L. Esposito, College of the Holy Cross

Yvonne Y. Haddad, University of Massachusetts

Tareq Y. Ismael, University of Calgary

Kenneth W. Stein, Emory University

This well-established series continues to focus primarily on twentieth-century developments that have current impact and significance throughout the entire region, from North Africa to the borders of Central Asia.

Recent titles in the series include:

Development and Social Change in Rural Egypt. Richard H. Adams, Jr.

The Egyptian Bureaucracy. Monte Palmer, Ali Leila, and El Sayed Yassin

Family in Contemporary Egypt. Andrea B. Rugh

Khul-Khaal: Five Egyptian Women Tell Their Stories. Nayra Atiya

The Rise of Egyptian Communism. Selma Botman

Egypt’s Other Wars

Egypt, 1940s.

1

Introduction

At the beginning of the 1940s public health was a topic of minor importance in Egyptian political life. At the end of the decade it had become an indispensable component of the national political agenda. Public awareness of the crucial importance of public health was aroused by the appearance of severe epidemics of falciparum malaria in 1942–44, relapsing fever in 1946, and cholera in 1947. Other diseases, such as schistosomiasis (bilharzia), ancylostomiasis (hookworm), ophthalmias (trachoma and other eye diseases), tuberculosis, and typhus, also existed before and during the 1940s but did not have the political impact of the malaria, relapsing fever, and cholera epidemics, which occurred during a critical and momentous historical context.¹

In the 1940s Egypt was in the throes of a nationalistic upheaval. Egyptian nationalists of all political ideologies observed that inhabitants of developed nations rarely suffered from the age-old epidemic diseases because modern science had learned how to prevent and treat them. They attributed the epidemics of the 1940s to Egypt’s status as an underdeveloped and colonized nation. The epidemics were therefore not only public health problems but also political problems that called for a political solution. In consequence the epidemics caused a massive mobilization in which King Faruq; majority and minority political parties; elite women volunteers; Islamic, nationalist, and communist groups; British authorities; experts from the Rockefeller Foundation and other international agencies; and, of course, the people in the infected regions all took part. The contenders for power in Egypt sought to win public goodwill not only through their efforts in the public health wars but also through their support for public health reform.

It would have been impossible to trace the events of the epidemics were it not for the lively, expressive, and relatively uncensored Egyptian press of the 1940s. Newspaper editorials, journalists’ reports, political cartoons, and diaries revealed political struggles and popular attitudes toward public health reform that are nearly absent from the government’s records. Oral interviews with persons who had participated in the events helped answer many questions. The press reports and the oral interviews were checked against the archival and parliamentary records and the secondary accounts. Accuracy can be assumed in none of these sources, but taken together they allow for a judicious reconstruction of Egypt’s wars against malaria, relapsing fever, and cholera.

Falciparum malaria (which is sometimes called malignant malaria), the first and most severe of the 1940s scourges, is caused by the Plasmodium falciparum parasite. The falciparum parasite is carried by the Anopheles gambiae mosquito, which likes warm, dark houses and breeds in shallow, standing, stagnant, sunlit water, sans vegetation (the five s’s memorized by students of malaria). The disease is prevented by mosquito eradication or by using screens, mosquito netting, clothing, and repellents to protect the skin from mosquito bites. Chloroquine phosphate taken orally usually confers protection in regions with infected A. gambiae mosquitoes. Patients gradually develop an immunity that is specific to the type of malaria they have experienced. Vaccines are being developed but are still in the experimental stage. Patients with falciparum malaria experience headache and chills followed by a rise in temperature. In severe cases headache, drowsiness, delirium, and confusion can lead to fatalities, especially in nonimmune populations. After about twenty to thirty-six hours the symptoms diminish, and the patient experiences diminished symptoms for three to four days. Untreated falciparum malaria has a high mortality rate, but antimalarial therapy is usually effective. Treatment is with chloroquine except in drug-resistant falciparum malaria, against which quinine and sulfa derivatives are used.² Less deadly forms of malaria are caused by three other parasites, Plasmodium vivax, P. malariae, and P. ovale, which are carried by Anopheles pharoensis, A. sergenti, and other anophelene mosquitos. In the 1940s malaria was the most widespread and dangerous disease in the Middle East.³ All types of malaria are still a threat in large areas of Central and South America, parts of the Caribbean, sub-Saharan Africa, Southeast Asia, and parts of the Middle East.⁴

Relapsing fever, the second of the series of epidemics, is caused by several species of Borelia spirochetes, which in Egypt are transmitted most commonly by lice.⁵ Relapsing fever thus shares a common vector with typhus but is a very different disease. Typhus, which is endemic in Egypt, strikes suddenly and with very severe symptoms; its survivors are nearly immune to further attacks. Relapsing fever, which is not endemic in Egypt, causes chronic symptoms that can recur for many years unless treated. Patients experience high fever, headache, vomiting, muscle and joint pain, skin rash, and delirium about six days after infection. The symptoms last for about three to five days and recur after a few days of apparent recovery. Mortality is generally low (up to 5 percent), but in epidemics of louse-borne fever cardiac failure may occur and mortality is consequently higher. The disease is prevented by delousing with DDT or other insecticides and treated with a single oral dose of tetracycline or erythromycin. Today, with basic hospital care, fatalities are very rare.⁶

Cholera, the third and most famous of the three epidemics, is caused by a vibrio, Vibrio cholerae, which is spread by the ingestion of water or food contaminated with the excrement of infected persons. The microbe cannot live outside the human host for more than a few hours, so its presence indicates a symptomatic or an asymptomatic cholera carrier in the vicinity. Patients initially experience diarrhea and vomiting, which often is misdiagnosed as food poisoning. In severe cases water and electrolyte depletion cause intense thirst, muscle cramps, sunken eyes, and wrinkled skin, which becomes black-and-blue from ruptured capillaries. The fatality rate can exceed 50 percent in untreated cases but is less than 1 percent with prompt treatment.

Anticholera vaccines have been sought since Robert Koch’s discovery of the Vibrio cholerae microbe during Egypt’s 1883 epidemic, but the results have generally been disappointing.⁷ In 1930, Leonard Rogers, the British cholera expert, reported positive results with the vaccine during a cholera outbreak in India; however, many medical researchers found his results unconvincing because his experiments had not been properly controlled.⁸ In 1970 researchers in the Philippines and Bangladesh concluded that the cholera vaccination did not give sufficient protection and that public-health officials should concentrate on upgrading sanitation and therapy centers.⁹ Experts today agree that avoidance of contaminated food and water remains the best means of prevention. Cholera is effectively treated with fluid and electrolyte therapy.

Egypt’s responses to the epidemics of malaria, relapsing fever, and cholera were shaped by public health policies and political attitudes that had evolved in the nineteenth and early twentieth centuries.¹⁰ In the early nineteenth century, Muhammad Ali (r. 1805–48), an Ottoman military officer, established himself as an Ottoman viceroy following Napoleon’s short-lived invasion. He then proceeded to develop Egypt’s economy and military forces and recruited a French physician, Antoine Barthèlme Clot (Clot Bey), to design his military and civilian public health services. In the late 1830s the British government, seeking to dominate the eastern Mediterranean, put an end to Muhammad Ali’s economic and military expansion. Clot Bey’s public health projects, however, continued in attenuated form for many years. In 1882 the British occupied and proceeded to rule Egypt indirectly through Muhammad Ali’s descendants and carefully chosen elites. The British authorities’ first concern was to reorganize Egypt’s finances to collect debts owed to European shareholders. To increase public revenues, British authorities concentrated on agricultural development. British engineers proceeded to expand land under irrigation by harnessing the waters of the Nile. In 1902 they completed a dam at Aswan. The engineers subsequently raised the dam and expanded and reinforced a series of barrages to control better the water flow. Nearly all of Lower Egypt was converted from basin to perennial irrigation so that two or three crops could be grown per year. These agricultural innovations, however, had far-reaching implications for public health conditions in Egypt. When perennial irrigation was expanded in 1902 and 1910, for example, bilharzia, hookworm, and other waterborne diseases spread into formerly uninfected areas of Lower and Middle Egypt. The Egyptian government raised the Aswan dam again in 1933–34. In the late 1930s, when Upper Egypt was being converted from basin to perennial irrigation, the waterborne diseases began to infect the population of Upper Egypt.

Lord Cromer (Evelyn Baring), proconsul and de facto ruler of Egypt from 1882 until 1907, was well aware of the need for medical and public health reform, particularly among the fellahin (peasants), who made up about 70 percent of the population. Most fellahin owned less than ten feddans of land; others rented from large landowners or hired themselves out as migrant workers. In 1883 Clifford Lloyd created the Department of Public Health, a branch of the Ministry of the Interior. Cromer’s 1885 report included a study by the newly appointed British surgeon major, who had found that there was only one trained Egyptian doctor for every thirty-two thousand Egyptians and that villagers were relying for medical care on the local barber or midwife who were poorly educated at best. The most common remedies, the surgeon major lamented, were bloodletting, magical charms, and anointment with oil.¹¹

Traditional (also called indigenous or empirical) medicine was considerably more complex than the surgeon major had suggested.¹² Tens of thousands of traditional practitioners provided most of the health care in Egypt. Midwives (dayas), health barbers (halaq al-sihhas), and certain religious personages (shaykhs and shaykhas) provided a variety of medical services. Very often charms or amulets were used to ward off disease.¹³ As elsewhere in the Middle East, many believed disease and other misfortune could be caused by a glance from a person or even an animal possessing an evil eye. To protect themselves against the evil eye or other evil spirits people often wore blue beads, the Hand of Fatima or other charms, and amulets containing Quranic inscriptions.¹⁴ Zar ceremonies were sometimes held to exorcise harmful spirits from sick persons.

For malaria, health barbers made scratches with cautery needles on the temples, cheeks, or shoulders of their patients to treat the disease.¹⁵ Cautery, bloodletting, and infusions of teas made from powdered sycamore, fenugreek, myrtle, and other leaves were used against the symptoms of fever that were caused by many diseases, including malaria, relapsing fever, and cholera.¹⁶

During the latter decades of the nineteenth century, many Egyptians, both educated and uneducated, had become aware that modern medicine (also called allopathic, Western, or cosmopolitan medicine) had advanced considerably and, with the discovery of vaccines and microbes, could prevent and treat certain diseases. Beliefs were often combined; people believed that, while microbes caused diseases, supernatural forces selected the individuals the microbes infected. And, while modern medicine could treat certain diseases effectively, so could traditional medicine. As a result, cautery, vaccines, and antibiotics were often used simultaneously. Many believed that traditional remedies were especially effective for joint problems and other chronic complaints, while modern medicine was more effective in treating epidemic diseases and emergency injuries.

These widespread popular beliefs were not reflected in official public health policies. British and Egyptian public health officials alike viewed traditional medical procedures as anachronisms that would disappear in time and rarely considered them in their medical and public health reform plans.¹⁷ At most, sporadic efforts were occasionally made to teach modern medical or nursing techniques to the midwives, health barbers, and other traditional practitioners.¹⁸

In the 1885 report Cromer said that it was impossible to expect rapid progress in sanitary reform because of a lack of funds. He therefore decided to provide efficient British supervision and gradual education of a native staff.¹⁹ This policy was to be followed for many years.

In 1892 Secretary of State for the Colonies Alfred Milner wrote that the Department of Public Health was one of the least satisfactory in the government service because, after initial difficulties, English interest in the matter died away.²⁰ The department was underfunded and poorly staffed. He complained, the towns and villages are filthy. The Canals, which are the only sources of water-supply to the bulk of the population, are subject to every kind of pollution. In the neighborhood of many populous places, there are ‘birkas,’ or stagnant ponds, which exhale miasma even when they are not—as they very often are—used for drinking. In the principal cities there is a certain amount of sweeping and carrying away of refuse, but there is absolutely no drainage. . . . The scope for improvement in sanitary matters at the present time is large enough to give employment for many years to the most ambitious and energetic reformer.²¹ Such a reformer did not materialize.

Severe epidemic diseases, however, encouraged the British authorities to strengthen the existing quarantine administration. In 1883, just one year after the British occupation, 58,511 deaths were reported from cholera.²² French opponents of the British occupation accused the British of having heedlessly imported cholera from India.²³ This accusation was to be repeated in 1947 by Egyptian nationalists. In 1896 and 1902 cholera again struck with devastating results.²⁴ Pilgrims returning from Mecca had apparently brought the disease into Egypt in each of the epidemics.²⁵ A series of plague outbreaks occurred from 1898 to 1905. In response British officials reorganized and carefully monitored the quarantine station at al-Tur, a border village in the Sinai. The al-Tur station had been established in 1855 and was used for the first time in 1862.²⁶ After it was upgraded following the 1902 epidemic, Egypt was free of cholera for many years. Plague outbreaks also diminished in severity.

Although progress was being made in alleviating Egypt’s burden of disease, in his 1903 report Cromer acknowledged that, from 1882 to 1903, the British authorities had allocated less than 1 percent of the total state expenditures for sanitation and education.²⁷ Funds expended by the British authorities came entirely from local taxes and other resources, not from the British government.²⁸ He lamented the dismal public health and medical conditions that the British found in 1882, but he believed that a few British doctors would be able to spread the light of Western science throughout the country, even though the school of medicine, founded by Muhammad Ali, had become a hotbed of ultra-Mohammedan and anti-European feeling.²⁹ The British doctors were duly employed, but student enrollment in the medical school was severely restricted.

In his 1906 report Cromer quoted from a statement made by the British director of the Qasr al-Ayni medical school, who had cautioned that the number of Egyptians admitted to the school should be carefully controlled. In his opinion, it is hardly possible to set loose on the country a more dangerous element than the needy medical man.³⁰ He apparently feared the political and nationalistic activities of Egyptians who were not only unemployed but also well educated. From 1886 to 1890, 112 students graduated from medical school. In the 1890s, as the British took control, the number dropped to ninety-nine from 1891 to 1895 and to only thirty-four from 1896 to 1900.³¹ The standards of the school were, however, rapidly brought into line with modern schools in Europe.³² After 1929, when the school returned to Egyptian administration, the number of graduates was slowly increased. Despite the increase in graduates the number of trained physicians remained inadequate for Egypt’s growing population.³³ Hakimas (visiting nurses) had been trained and licensed since the nineteenth century, but their numbers were also inadequate.³⁴

At the turn of the century adequate medical facilities existed only in European neighborhoods in Cairo and Alexandria, where, after the cholera epidemics, British authorities improved the potable water, sewage, and sanitation services.³⁵ The Department of Public Health funded hospitals that had been established by Muhammad Ali and his grandson Ismail (r. 1863–79) and introduced numerous improvements. Most of the better hospitals were, however, privately owned, and each of the major European communities raised funds and built its own. There were, for example, Greek, Jewish, Italian, and Anglo-American hospitals. In addition a few Christian missionary societies established hospitals that served the local Egyptian population. American Presbyterians operated hospitals at Tanta and Aswan and trained Egyptian women as nurses. After the turn of the century the Department of Public Health occasionally sent traveling tent hospitals to rural areas and carried out programs for smallpox vaccination and campaigns against the eye diseases that afflicted so many Egyptians.³⁶

Two Egyptian-run, private, volunteer organizations specialized in medical care: the Mabarra Muhammad Ali (the Muhammad Ali Benevolent Society) and the Red Crescent Association (Hilal al-Ahmar), the name taken by International Red Cross organizations in Muslim countries. (Because most of the English-language sources rather contradictorily use the