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Athens Appealing: Reforming Greek Public Health
Author: Jeffrey Levett
Full-article Wall Street International, 27 March 2017
By Jeffrey Levett
One hundred years ago several eminent scholars with their fingers on the pulse of international developments in public health, found it deplorable that government remained unmoved for so long to the plight of the population and the abysmal environmental conditions of Greece. Being romantics they were doubly deplored in the country where Hygiene, goddess of public health, once held sway.
This year , the Hellenic Ministry of Health will be celebrating its first 100 years [Να τα χιλιοστισει!]. It presents a new and significant opportunity to focus on reform and to change the course of public health in Greece, no easy affair.
Greek population health is now severely compromised by austerity; a baby born today, is more disadvantaged than one born yesterday; life’s quality is falling, poverty is rising and months are being whittled from life. Greece is a land of enhancing disparity and of multiple instalments, payments for even life’s very basics [water, electricity]. Unrelenting unemployment is driving despair, illness and youth’s reluctant migration. The absorbing capacity of Greece to dissipate the effects of the ongoing creeping disaster is reaching its limit. Population resilience urgently needs rebuilding!
Greek public health is still overly dominated by medicine and there is no clear policy for either. Given the number of doctors passing through parliament, this is at least paradoxical. The health sector is inefficient, resources are unequally distributed and it suffers from a relatively low degree of transparency. The School of Public Health needs immediate strengthening!
To reform public health, sustainable political will is vital. To be effective it must be as strong as in the days of Eleftherios Venizelos when a short-lived revolution precipitated the creation of the School of Public Heath [Hellenic School, 1929], first conceptualised in 1905.
According to one report circa 1950 Greece could have had an enviable health sector if it had applied the advice of those eminent scholars and the experts of the League of Nations when the Hellenic School was established?
The Hellenic School was a rational, scientific response to the miserable conditions of health an unrelieved state of morbidity for the Greek people, ever since the Greek War of Independence . John Capodistria, as Governor of the new Greece, took measures aimed at bringing order from chaos. At that time Daniel Webster was prompted to request Congressional help for Greece, which he said was fighting against unprecedented odds for the common experience of human existence.
The work of the Hellenic School ensured major contributions to wellbeing. It helped place Greece in the league of modern nations. Notwithstanding its eradication of malaria and the control of tuberculosis, this prestigious School was buffeted by the medical establishment, dominated by an obsolete bureaucracy, trapped in a web of paradoxical legalese and constrained by dictatorship, which cut it off from the international community. In the 1950’s, it was saved by a spiking of malaria, in 1969 it survived following an intervention by prestigious scientists who said, that no state, with a School, has ever abolished it and its rejuvenation became a high priority of Constantine Karamanlis on his return from exile in France . “Rejuvenation” was reluctantly encapsulated into plans for the national health sector [Spiros Doxiadis], which failed as a result of friendly fire. Once again it just managed to survive as a result of a presidential edict , one of the last breaths of the outgoing government. It was more a case of favoured status [rousfet] rather than a rational decision.
In 1984, it took a significant step forward when new subject matter was added to the curriculum [health systems management, systems theory, biomedical technology, economics, health politics and sociology] and the interdisciplinary concept of public health was reinforced. The major innovations were new post graduate programmes one inhealth service management, which was covered by law and functions today, the other an unofficial and short-lived management of appropriate health technologies, which included pharmaceuticals. In 1994 graduate education in public health was considered satisfactory but insufficient by an international panel.
From 1990 to 2012 the Hellenic School conducted numerous programs in the greater geographical region, PHARE, INTERREG, Greek Technical Aid [Balkans, Eastern Mediterranean, and Black Sea] and worked with the World Association of Disaster Emergency Medicine [WADEM]. It designed a practical graduate programme on disaster management for Greece and a theoretical incident management system for the Balkans. A strong but short relationship was developed with the Ministries of Health and Foreign Affairs for crisis management. One important Balkan engagement was with a United Nations structure with activities in human security and the knowhow of the Hellenic School in the Balkans was later used by the Public Health Network of SEE.
Changes in the region influencing health and the health sector as a result of transition, ethnic cleansing and sanctions were closely followed and the Hellenic School responded with a concrete policy. Its activities were supported by the Greek authorities and the European Commission, which also enabled it to reconnect to the international community [ASPHER, FICOSSER, AUPHA].
Much of this was described during the 38th annual General Assembly of the Association of Schools of Public Health in the European Region [ASPHER]. The Athens Assembly marked the first one half century of life of ASPHER [1966- 2016]. Representatives from its member institutions met in the historic Hellenic School [one of the first in Europe] to debate the future of European public health and ratify the Athens ASPHER Accord. It was attended by representatives of the Ministry of Health.
The Accord expressed grave concern for the problems engulfing Europe and their impact on public health [austerity, migration, terrorism, environmental degradation, epidemic threats]. It appealed to the Greek authorities to let its historic School of Public Health, work unimpeded. The Accord petitioned politics, the European Parliament and all individual administrations in the European Union member states to help fashion a more equal, stable and democratic world. It argued that a more positive and proactive approach to Schools of Public Health will send out a strong signal serving sustainable development and European stability. It called for the rejection of the “ugly duckling” role of public health and demanded much more support for its related Schools. The representatives of public health firmly believe that population health, peoples’ wellbeing and human rights will benefit if the issue of its related institutions is moved up the European political agenda.
The year 2016 was ASPHER’s platform in Athens to reach out to the European political leadership and demand greater support for public health as a scientific, social and moral obligation. It proclaimed a great need to re-conceptualize Public Health, socially and politically as a crucial avenue to promote rational socioeconomic development. It underscored that protection and promotion of minority and migrant health is of fundamental importance to public health. It recalled the horrendous population displacements of WWII and the holocaust, displacements concomitant with the collapse of the Ottoman Empire and more recent ones in the Balkans.
Speaking before the National Convention of the Medical Committee for Human Rights , Martin Luther King Jr., proclaimed that of all the forms of inequality, injustice in health is the most shocking and the most inhumane. President Johnson declared war on poverty and Medicaid and Medicare got off the ground. Jonathan Mann termed the juxtaposition of health and human rights, mankind’s new ethical space. Today, it is being vandalised and dismantled by greed, globalisation and politics; Obamacare under siege, Greece locked in austerity and America questioning the merits of WHO.
Our living space is threatened by radioactive pollution and the threat of nuclear winter grows. Ironically, in and around Chernobyl  today , poverty is the greater threat. Of note, is that nuclear sciences in medicine, nuclear research, radioprotection and disaster public health were strong agenda items in the early days of WHO and the European Community.
Public health is an outcome of disasters, filth diseases, the industrial revolution and urbanization. Both political will and charismatic individuals played a crucial role in its development. Public health is also an instrument for preparedness and response strengthened with the instruments located in Public Order, Civil Protection, and Foreign Affairs. At the best of times public health is almost invisible while when things go badly; its services are soon recalled. In times of authoritarian government its autonomy is undermined and its institutions have been destroyed.
It is incredible that interdisciplinary public health has not yet managed to capture the ears of the international community and that after a half century of work in post graduate education of an important Network of Schools of Public Health, vital contributions over nine decades of one of Europe’s first Schools and with one 100 years of effort by the Hellenic Ministry of Health.
During the upcoming centennial celebration, public health will be discussed again, with yet another chance to exert influence on the current Greek authorities. If the WHO can capture half an ear of the Greek authorities it will be a significant success. Dialogue is a necessity but it is insufficient. Action must replace the typical back peddling of the status quo and political infighting. Within Greek-WHO collaboration the latter could go beyond dialogue and act more political as in the days of Halfdan Mahler, Stampar medalist for his promotion of primary health care. Mahler succeeded for a short while to make health more political. Perhaps the Greek authorities can find the courage to bypass the political cost and go beyond the simple recognition of public health past.
One big question is whether the will to act within the complex problem space of Greek health is sufficient to the task. This space according to the current administration is home to a humanitarian disaster, which has precipitated a down turn in population health and an unequal access to health services. Within the health sector, the National Health System  needs reorganization, new management and additional resources, the network of “therapeutic” health centers needs a major reorientation towards community; nursing needs of medicine must be addressed while health promotion from childhood to full maturity is now imperative. An adequately supported School of Public Health can train for strategy development, introduce new ideas and models and help improve health sector leadership. A School of Public Health is of vital importance to pulling back from the health damage coming from the humanitarian crisis and promoting sustainable development a social need that defies entry.
Reform can make its mark and immediately if the less than perfect transformation of the Hellenic School of Public Health , is quickly completed, a simple corrective challenge. Health and social service function can be better ensured if core competences in public health have a raised voice.
The still unused by ASPHER and unread by politicians Athens ASPHER Accord  has gone on record to urge without reservation that all impediments to the function of the Hellenic School are removed and to demand a level of European support for public health commensurate to the size and complexity of the problem space it now faces in Greece and throughout Europe.
A positive response to these demands would be for the common good of all Europeans. Not to respond, will result in a still poorer Greece.
Happy birthday Hellenic Ministry of Health, an even more productive 2nd half century, ASPHER and good luck WHO!
Levett Jeffrey, Public health in Greece, http://nrdisaster.blogspot.gr/2014/11/blog-post_11.html
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Levett Jeffrey. From cradle of European civilization to grave austerity: does Greece face a creeping health disaster? Prehosp Disaster Med. 2013;28(6):1-2.
Levett Jeffrey. The Greco Report: forward in health 2014 remembering the past. International Journal of Caring Sciences. 2014. 7(2):333.
Ulrich Laaser, Evelyne de Leeuw, Stock C Editors, Scientific Foundations of Public Health Policy in Europe, Juventa Verlag Weinheim and Munchen 1995
Ritsatakis A, Levett J, Kyriopoulos J,“Neighbours in the Balkans: Initiating a dialogue for health”, Athens School and WHO
Cristina Vladu, Role and development models for primary health care in Europe,Center for Community Policies, Bucharest
Levett Jeffrey Disastrous Events and Political Failures, PrehospDisaster Med.2014;29(6):553-554.
Levett Jeffrey. First half century of the Association of Schools of Public Health in the European Region. SEEJPH 2016, Vol. 6. DOI 10.4119/UNIBI/SEEJPH-2016-113
Levett Jeffrey, Public health’s curiosity cabinet and the swallows of Fukashima, LIU, Brooklyn Public Lecture, Oct. 1 2015
Jeffrey Levett is Professor Emeritus and founding Dean of the National School of Public Health, Athens . He is a member of the Executive Board, European Center for Peace and Development, United Nations University for Peace, Belgrade, Serbia and has directed a Center in Kosovo and participated in a doctoral biomedical engineering program in Croatia. He is currently in the process of designing the 5th ECPD Youth Forum, Belgrade [28-29 October, 2017] under the banner, YOUTH: CITIZENS OF THEIR WORLDS; CITIZEN OF EUROPE. [See http//wsimag.com/economy-and-politics/24279-bringing–out-balkan-youth] This year Jeffrey Levett completes a relationship of 33 years with ASPHER.