University of California Berkeley
Regional Oral History Office University of California
The Bancroft Library Berkeley, California
Aramco Medical Department Oral History Project
HEALTH AND DISEASE IN SAUDI ARABIA:
THE ARAMCO EXPERIENCE, 1940s- 1990s
VOLUME I
Interviews with
Richard Daggy
Armand P. Gelpi
Richard Handschin
Julius W. Taylor
Elinor Nichols
Dorothy McComb
Robert and Patricia Oertley
Ivor Morgan
Virginia Dooling
Richard Perrine
Ahmed Mustafa
Bernard J. Eggerman
Gordon Flom
Edited, and with an Introduction by
Armand P. Gelpi
Interviews Conducted by
Carole Hicke
in 1996 and 1997
Copyright 1998 by The Regents of the University of California
-f
Since 1954 the Regional Oral History Office has been interviewing leading
participants in or well-placed witnesses to major events in the development of
Northern California, the West, and the Nation. Oral history is a method of
collecting historical information through tape-recorded interviews between a
narrator with firsthand knowledge of historically significant events and a well-
informed interviewer, with the goal of preserving substantive additions to the
historical record. The tape recording is transcribed, lightly edited for
continuity and clarity, and reviewed by the interviewee. The corrected
manuscript is indexed, bound with photographs and illustrative materials, and
placed in The Bancroft Library at the University of California, Berkeley, and in
other research collections for scholarly use. Because it is primary material,
oral history is not intended to present the final, verified, or complete
narrative of events. It is a spoken account, offered by the interviewee in
response to questioning, and as such it is reflective, partisan, deeply involved,
and irreplaceable.
************************************
This manuscript is made available for research purposes. All
literary rights in the manuscript, including the right to publish,
are reserved to The Bancroft Library of the University of
California, Berkeley. No part of the manuscript may be quoted for
publication without the written permission of the Director of The
Bancroft Library of the University of California, Berkeley.
Requests for permission to quote for publication should be
addressed to the Regional Oral History Office, 486 Library,
University of California, Berkeley 94720, and should include
identification of the specific passages to be quoted, anticipated
use of the passages, and identification of the user.
It is recommended that this oral history be cited as follows:
To cite the volume: "Health and Disease in Saudi
Arabia: The Aramco Experience, 1940s- 1990s, " an oral
history conducted 1996-1997 by Carole Hicke, Regional
Oral History Office, The Bancroft Library, University
of California, Berkeley, 1998.
To cite an individual interview: [ex.] Interview with
Richard Daggy, an oral history conducted in 1996 by
Carole Hicke in "Health and Disease in Saudi Arabia:
The Aramco Experience, 1940s- 1990s, " Regional Oral
History Office, The Bancroft Library, University of
California, Berkeley, 1998.
Copy no.
Cataloging information
Health and Disease in Saudi Arabia: The Aramco Experience, 1940s- 1990s,
1998, 2 vols., xxiv, 799pp.
Recollections of fourteen medical professionals in Saudi Arabia who from
the 1940s through the 1990s participated in a unique program to mitigate
and solve not only the health problems of Aramco corporate employees and
their dependents but those of the local population as well. Eliminating
malaria; Harvard-Aramco Trachoma Project; Dhahran Health Center and
outreach clinics in oasis villages; other health and disease problems:
smallpox, Q fever, tuberculosis, sickle cell anemia, schistosomiasis,
ascaris pneumonia, cholera; maternal and child health program; nursing
staff; psychiatric care; surgical clinic; preventive medicine measures;
ob/gyn clinic; dental care; new hospital facilities.
Interviews with Richard Daggy (b. 1914), medical director; Armand P. Gelpi
(b. 1925), chief, medical services; Richard Handschin (1918-1997), medical
director; Julius William Taylor (b. 1922), medical director; Elinor Nichols
(b. 1927), wife of Roger Nichols, director, trachoma project; Dorothy
McComb (b. 1931), researcher, trachoma project; Robert Oertley (b. 1925),
director, preventive medicine, and wife Pat Oertley; Ivor Morgan (b. 1914),
chief, ob/gyn services; Virginia Dooling (b. 1934), nurse supervisor;
Richard Perrine (b. 1918), chief, internal medicine; Ahmed Mustafa (b.
1932), chief, internal medicine; Bernard J. Eggerman (b. 1927), chief,
dental services; Gordon Flom (b. 1927), coordinator, medical development
and construction. Written essay by John C. Snyder, dean, Harvard School of
Public Health.
Edited, and with Volume Introduction by Armand P. Gelpi.
Interviewed 1995 to 1997 by Carole Hicke, Regional Oral History
Office, The Bancroft Library, University of California, Berkeley.
ACKNOWLEDGEMENTS
The Bancroft Library, on behalf of future researchers, wishes to
thank the following individuals and organizations whose contributions have
made possible this oral history of the Aramco Medical Department. In
particular, we acknowledge the initiative, dedication, and countless hours
of work by Dr. Armand P. Gelpi, without whose efforts this project could
not have been done.
PATRON
Saudi Arabian Oil Company
DONORS
Paul Arnot
Elizabeth Arnot, in memory of Paul Arnot
Chevron (matching)
Richard Daggy
Carlton Dawson, in memory of Lewis V. Coleman
Lois and Gordon Flom
Dorothy McComb
Ivor I . Morgan
Richard P. Perrine
Peter and Ellen Speers
Julius W. Taylor
TABLE OF CONTENTS- -Health and Disease in Saudi Arabia: The Aramco
Experience, 1940s-1990s
INTRODUCTION by A. P. Gelpi i
VOLUME HISTORY xv
RICHARD H. DAGGY, PH.D., DR. P.H., PREVENTIVE MEDICINE IN SAUDI
ARABIA, 1947-1964 xviii
CONTENTS xix
INTRODUCTION by A. P. Gelpi xx
INTERVIEW HISTORY by Carole Hicke xxi
BIOGRAPHICAL INFORMATION xxii
I BACKGROUND AND EDUCATION 1
JI JOINING ARAMCO 2
Applying and Interviewing 2
Moving to Saudi Arabia 3
III ELIMINATING MALARIA IN SAUDI ARABIA 5
Identifying the Problem 5
Taking the Malaria Survey: A Ten-Year Study 6
Malaria Controls 8
Meeting the King 14
Other Preventive Medicine Programs 15
Smallpox 15
Looking for a Trachoma Vaccine 18
Public Health Program 18
IV WORK AFTER ARAMCO 23
Associate Dean, Harvard School of Public Health 23
University Associates 24
Some Statistics and Evident Changes 25
ARMAND P. GELPI, M.D., ARAMCO MEDICAL SERVICES: 1959-1969
CONTENTS 28
INTRODUCTION by A. P. Gelpi 30
INTERVIEW HISTORY 31
I BACKGROUND 33
Growing Up in Denver and California 33
Pre-med Training in the U.S. Navy, 1943-1945 34
Medical School 35
* Internship and Military Service During the Korean War 37
Residency in San Francisco and San Jose, 1952-1955 40
Practicing Medicine in the V.A. Health Care System 41
Private Medical Practice 42
II EMPLOYMENT WITH ARAMCO, 1959 43
Job Interview 43
The Move to Dhahran, Saudi Arabia 45
Aramco Health Care in Saudi Arabia Before 1959 46
Aramco s Dhahran Health Center 47
Community Clinics 50
More About Dhahran Health Center 50
III FACILITIES AND PATIENTS 52
Contract Facilities 52
Trips to Qatar in 1960 and 1968 54
Health Care at DHC and Other Aramco Facilities: Patients 57
Community Life 58
Aramco Medicine 58
Aramco Provides Medical Services to the Royal Family 62
The Persian Gulf Medical Society and Aramco s Medical
Department 64
IV HEALTH AND DISEASE IN SAUDI ARABIA 67
Smallpox 67
Malaria 68
Aramco s Health Care Program and the Saudi Government 70
More about Aramco and Malaria Control 72
Trachoma and Aramco s Trachoma Research Project 73
Q Fever in Saudi Arabia 75
Pulmonary Ascariasis 79
Cancer 82
Conference in Shiraz, Iran: G6PD Deficiency and Favism 85
Sickle Cell Trait and Sickle Cell Disease 90
Schistosomiasis 96
Pulmonary Tuberculosis 98
Hepatitis 99
V MEDICAL DEPARTMENT ADMINISTRATION 103
Reporting to Aramco Management 103
Hiring 104
District Visits and Medical Education 107
More on the Journal Club 109
VI RESIGNATION AND RETURN VISITS TO DHAHRAN 111
Leaving Aramco 111
Medical Research in Dhahran, 1974-1978 112
RICHARD HANDSCHIN, PREVENTIVE MEDICINE AND MEDICAL DIRECTOR:
1958-1968 114
CONTENTS 115
INTRODUCTION by A. P. Gelpi 116
INTERVIEW HISTORY 117
BIOGRAPHICAL INFORMATION 118
I BACKGROUND 119
II JOINING ARAMCO 121
Interview and Hiring 121
Moving to Saudi Arabia 122
III EPIDEMIOLOGIST 124
Annual Malaria Survey 124
Other Staff Members and Personnel 124
Tuberculosis and Smallpox 125
Personnel in Preventive Medicine 126
IV CHIEF OF PREVENTIVE MEDICINE 128
Responsibilities 128
Maternal and Child Health 129
Health Education Program 132
Trachoma Research 134
Malaria Research 134
Occupational Health Program 135
Statistical Data on the Impact of the Preventive
Medicine Program 136
V MEDICAL DIRECTOR, 1964-1968 139
Outpatient Clinics: Statistics on Patients 139
Developing Public and Private Medical Services 141
Relationships with Company Management 142
Hiring and Educating Staff 144
Dr. Ivan Alio 146
Lecturing at the American University of Beirut 148
More Statistical Data About Changes 149
Crucial Leadership of Dr. Richard Daggy 150
More Data on Patient Care 154
Need for Nursing Staff 156
VI OVERVIEW: GOALS AND ACCOMPLISHMENTS 157
JULIUS W. TAYLOR, SURGEON AND MEDICAL DIRECTOR: 1954-1978 162
CONTENTS 163
INTRODUCTION by A. P. Gelpi 164
INTERVIEW HISTORY 165
BIOGRAPHICAL INFORMATION 166
I BACKGROUND, EDUCATION, MILITARY SERVICE 167
II JOINING ARAMCO 170
Interview and Appointment 170
Moving to Dhahran, December 1954 171
IH DHAHRAN HEALTH CENTER 174
History 174
Patients and Cases 175
Concession Agreement 175
OB/GYN; Burns 177
Dental Service 177
Trauma 178
Staff Personnel 179
Smallpox 180
Medical Care Responsibilities: Dependents 182
Facilities and Living in Dhahran 183
The New Hospital 186
Developing Psychiatric Care 187
Accreditation 189
Medical Training 19A
IV CAREER DEVELOPMENT AND RESPONSIBILITIES 196
Chief Surgeon, 1961-1963: Hiring Staff and
Relationships with Management 196
First Open-Heart Surgery at Aramco 201
First Lung Removal 201
Evacuation Procedures 202
Contract HospitalsAnother Change 203
Attractions of Life with Aramco 20A
Chief of Staff, Clinical Services, 1963-1968 210
Dental Care 210
Administrative Matters 212
Medical Director, 1968-1978 212
More on Contract Hospitals 215
Medical Care for the King and Royal Family 218
Early Saudi Medical Practices 221
Preventive Medicine and Research 22A
Tapline Stations 228
Recruiting and Hiring Staff 229
Impact of Increasing Saudi Ownership Participtation 232
Emergency Preparedness 235
A Riot in Dhahran 237
V OVERVIEW 240
TRACHOMA PROJECT- -JOHN C. SNYDER 243
INTRODUCTION by A. P. Gelpi 24 A
The Harvard /Aramco Trachoma Project 245
ELINOR NICHOLS, ROGER NICHOLS AND THE TRACHOMA PROJECT: 1956-1982 249
CONTENTS 250
INTRODUCTION by A. P. Gelpi 251
INTERVIEW HISTORY 252
BIOGRAPHICAL INFORMATION 253
I JOINING ARAMCO 25 A
Roger Nichols s Education and Internship 25A
Looking for an Overseas Position: 1956 255
Moving to Saudi Arabia 256
II THE TRACHOMA PROJECT 258
Roger Nichols Gets Involved 258
Nichols Heads the Project 259
Background on Roger and Elinor 261
Trachoma Research: Isolating the Disease 266
The Next Objective: Developing a Vaccine 268
Nichols Gets A Case of Trachoma Himself 272
Other Medical Personnel 274
III POST-ARAMCO ACTIVITIES 276
Nichols Becomes Director of Boston s Museum of Science,
1982 276
Founding the University Associates for International
Health
Director, Museum of Science, 1982 283
V LIFE IN SAUDI ARABIA 284
Raising a Family 284
Curing Trachoma: A Moral Dilemma 284
Desert Explorations and Other Expeditions 286
Tom Barger 288
History and Archeology 290
Travels 291
DOROTHY McCOMB, TRACHOMA PROJECT: 1953-1976 292
CONTENTS 293
INTRODUCTION by A. P. Gelpi 294
INTERVIEW HISTORY 295
BIOGRAPHICAL INFORMATION 296
I TRACHOMA RESEARCH PROJECT 297
Starting Work with the Project 297
Dr. Snyder Undertakes the Reserach: Problems of Isolation 298
Relationship Between Harvard and Aramco 300
Village Surveys 302
Collecting Samples 304
Learning about Arab Culture and Undertaking Village Visits 306
Successful Isolations, then Vaccination 310
Ten-Year Follow-up Visits 312
Vaccines and Cures 315
Dr. Roger Nichols 317
Dr. Robert Oertley 319
Dr. Richard Daggy 320
Other Personnel 321
II WINDING UP THE TRACHOMA PROJECT 323
ROBERT AND PATRICIA OERTLEY, RAS TANURA, ABQAIQ, AND DHAHRAN
MEDICAL FACILITIES: 1956-1982 326
CONTENTS 327
INTRODUCTION by A. P. Gelpi 328
INTERVIEW HISTORY 329
BIOGRAPHICAL INFORMATION- -Patricia Oertley 330
BIOGRAPHICAL INFORMATION- -Robert Oertley 331
I BACKGROUND 332
Childhood on the Farm 332
Cornell College 334
Military Service 335
II BECOMING A DOCTOR 337
Medical School, University of Iowa 337
Internship 340
Work in the Belgian Congo: 1963 340
III ARAMCO: 1963-1982 343
Joining Aramco 343
Ras Tanura Clinic: Family Physician 344
Abqaiq Clinic: Medical Administrator 349
Epidemiology 356
Record-Keeping Procedures 362
Nursing Staff 363
Moving to Dhahran 365
Field Director, Trachoma Research Program 367
Director of Preventive Medicine 369
Camel Trip into the Desert 374
IV PAT OERTLEY 377
Background and Education 377
Early Work Experiences 379
Joining Aramco 383
Ras Tanura 383
Marriage and Move to Abqaiq 386
Dhahran 388
Dhahran Medical Facilities and Other Services 391
Adjusting to Cultural Differences 393
Leaving Saudi Arabia 398
Aramco Management Support 404
VOLUME II
IVOR MORGAN, OBSTETRICS /GYNECOLOGY: 1952-1967 406
CONTENTS 407
INTRODUCTION by A. P. Gelpi 408
INTERVIEW HISTORY 409
BIOGRAPHICAL INFORMATION 410
I BACKGROUND 411
Childhood, Education, and Early Career 411
II JOINING THE COMPANY 415
Description of Facilities 418
Change Within the Profession, a New Life 418
Accreditation and High Level of Service 419
Interpersonal Communication 420
Saudi Patients and Cases 421
III OBSTETRICAL /GYNECOLOGICAL PROBLEMS PECULIAR TO THE MIDDLE
EAST EXPERIENCE 1950s- 1960S 423
Some Anecdotal Material 423
Ruptured Pregnant Uterus 425
IV LIFE IN SAUDI ARABIA 428
Musings While on the Road Between Abqaiq, Dhahran, Ras
Tanura 428
More Anecdotes 429
V MORE ON THE OB/GYN CLINIC 432
Doctors Brown and Alexander 432
Abqaiq and Ras Tanura Clinics 433
Exploration Camps 435
Clinical Standards; Accreditation 438
"The Operation Must Go On" 442
Nursing Staff 443
A Trip to Dammam 445
Arab Patients 447
VI OVERVIEW 450
Aratnco s Medical Contributions to Saudi Arabia 450
Untold Story of the Bigger Picture: Aramco 453
VIRGINIA DOOLING, ARAMCO CLINIC NURSE, 1977-1981 456
CONTENTS 457
INTRODUCTION by A. P. Gelpi 458
INTERVIEW HISTORY 459
BIOGRAPHICAL INFORMATION 460
I JOINING ARAMCO: 1977 461
Reasons for Applying 461
Moving to Saudi Arabia 462
II ORIENTATION AND RESPONSIBILITIES 463
Dhahran Orientation 463
Assignment to Abqaiq: Assistant to Chief Nurse 463
Udhaliyah Camp: 1977-1981 466
Al-Hasa, Hofuf 467
Immunization Program 469
Health Education 469
Medical Disaster Plan 471
III LIFE IN SAUDI ARABIA 472
Multicultural Diversity 472
Multiple Births 475
Jubail: A Planned City 480
Travels 481
Lifestyle 481
RICHARD PERRINE, INTERNAL MEDICINE AT ABQAIQ AND DHAHRAN: 1960-1980 485
CONTENTS 486
INTRODUCTION by A. P. Gelpi 487
INTERVIEW HISTORY 488
CURRICULUM VITAE 489
BIOGRAPHICAL INFORMATION 491
I EDUCATION AND EARLY WORK EXPERIENCES 492
Childhood and Education 492
Internship and Residency 493
Practicing in Appalachia 493
II EARLY DAYS WITH ARAMCO 495
Joining the Company in 1960: How and Why 495
Lifestyle and Opportunity for Travel 496
Moving to Saudi Arabia 498
Abqaiq 499
III ARAMCO MEDICAL DEPARTMENT 500
Supervising Physician, Abqaiq Health Center: 1960-1963 500
The Clinic 500
Patients 503
Friends and Neighbors 504
Medical Facilities 506
Diseases and Diagnosis 506
Medical Conferences 508
Tuberculosis and Brucellosis 509
Teaching and Consulting 510
Chief, Medical Liaison Division, Dhahran Health
Center, 1964-1969 512
Liaison Responsibilities 512
Outside Hospitals 512
Handling Medical Records 515
Increasing Efficiency and Controlling Costs 516
Medical Personnel, Diseases, and Patients 519
Saudi Patients 522
Chief, Internal Medicine Service, 1969-1978 526
Appointment and Early Responsibilities 526
Growth in the 1970s 528
Research 530
Research Colleagues 534
General Public Patients 538
Further Education 540
Senior Internist, 1978-1980 541
AHMED MUSTAFA, INTERNAL MEDICINE: 1960-1984 543
CONTENTS 544
INTRODUCTION by A. P. Gelpi 545
INTERVIEW HISTORY 546
BIOGRAPHICAL INFORMATION 547
I BACKGROUND 550
Childhood in Egypt 550
Education 551
II ARAMCO-- EARLY DAYS 552
Joining the Company in 1960 552
Impressions of Dhahran 553
Outpatient Clinic 554
Senior Physician, Employee Clinics 555
Internal Medicine Service and Liaison Physician 558
Ascaris Pneumonia 560
Treating an Aramco Executive 561
Residency and Fellowship at Tufts Medical Service,
Boston City Hospital, 1971-1974 563
Back to Aramco Internal Medicine Department: New
Equipment 566
Hiring More Staff 569
Committees and Other Activities 570
III RETIREMENT AND REFLECTIONS 575
ODE TO DR. MUSTAFA 577
BERNARD J. EGGERMAN, DENTISTRY: 1958-1987 578
CONTENTS 579
INTRODUCTION by A. P. Gelpi 580
INTERVIEW HISTORY 581
BIOGRAPHICAL INFORMATION 582
I * BACKGROUND: CHILDHOOD AND EDUCATION 585
Family 585
Childhood and Education 587
Military Service and Early Work Experience 589
II HIGHER EDUCATION AND EARLY CAREER 594
University of Illinois 594
Working for Minerallac Electric 595
Hospital Work 597
Dental School, Northwestern University 598
Army Dentistry 599
Teaching at Northwestern 600
III ARAMCO 603
Joining the Company 603
Moving to Saudi Arabia: Starting the Tennis Club 605
Dhahran Health Center 610
Chief of Dental Services 611
History of Aramco s Dental Group 613
Training Dental Assistants 614
Dhahran Dental Clinic 618
The Contract Hospitals 621
Taking More Training at Northwestern; Adding Staff 627
Executive Management Help 630
Training Program with University of Kentucky 630
Preventive Dentistry 631
Life in Dhahran 633
Aramco s Medical Research 634
Trachoma and Tetanus 634
Sickle Cell Anemia 635
Community Activities 636
Hiring Dentists 637
Hospital Accreditation 639
More on Recruiting 640
Water Fluoridation and Diet Services 642
Leaving Aramco 643
GORDON FLOM, HOSPITAL ADMINISTRATION: 1969-1989 647
CONTENTS 648
INTRODUCTION by A. P. Gelpi 649
INTERVIEW HISTORY 650
BIOGRAPHICAL INFORMATION 651
I BACKGROUND 654
Education 654
Early Work Experiences: Hospital Administration 654
II ARAMCO 657
Joining the Company 657
Moving to Saudi Arabia: 1969 660
Administrator of Supporting Health Services 660
Management Grid 663
A Newly Created Job 664
Midwives and Nurses 665
First Impressions: Description of the Facilities 665
A Wedding 667
Outlying Clinics 668
Out-of-Kingdom Training for Saudis 669
Personnel and Staff 673
III COMPANY EXPANSION IN THE 1970S 675
Coordinator of Medical Development and Construction,
1975 675
Building New Hospital Facilities 676
King Faisal Specialty Hospital 680
Aramco Expansion and the New Hospital 680
New Facilities in Outlying Districts 683
Project Management Department 685
Equipment Purchases 686
Reporting 686
Cholera Epidemic 687
Health Education Fairs 688
Nationalization 688
Views of a Patient 690
Community Activities 692
TAPE GUIDE 696
APPENDIX
Curriculum Vitae, Armand P. Gelpi, M.D. 699
"Agriculture, Malaria and Human Evolution: A Study of
Genetic Polymorphisms in the Saudi Oasis Population,"
by Armand P. Gelpi, M.D., in Saudi Medical Journal Vol. 4
No. 3, July 1983 706
Biographical Data, Richard Handschin, M.D. 712
Curriculum Vitae, Julius W. Taylor, M.D. 717
Curriculum Vitae, Roger L. Nichols, M.D. 723
"Aramco-Harvard Search Proves Trachoma Vaccine," Sun & Flare
[Dhahran, Saudi Arabia], October 30, 1963 734
Letter from Roger Nichols to Sam Bell, July 17, 1957 736
Letter from Elinor Nichols to her parents, November 14, 1957 738
Curriculum Vitae, Dorothy Elizabeth McComb 741
"Trachoma Research Program," Chlamydial Research Publications,
1954-1981, published jointly by Aramco, Dhahran, Saudi Arabia,
and Harvard School of Public Health, Boston, Massachusetts 746
Robert Oertley, M.D., handwritten biographical information 772
"Vaginal retention of a term fetus following labor and expulsion
of the fetus from the uterus," by Ivor I. Morgan, M.D., in
American Journal of Obstetrics and Gynecology. Vol. 79, No. 6,
July 1960 773
Publications, Richard P. Perrine, M.D. 776
Resume, Gordon K. Flora 779
GLOSSARY 781
i
INDEX 791
INTRODUCTION
Early in 1995, this editor learned that The Bancroft Library at
the University of California, Berkeley, had produced a collection of
oral histories contributed by six retirees from the Arabian American Oil
Company (Aramco) . It told the story of developing and producing oil as
a joint effort by Americans and Saudis. What made this collection
unique is that its contributors played major roles in Aramco s
management during its developmental years, before the company was turned
over to the Saudi government as Saudi Aramco.
Now oil productionwhich is what Aramco did, and did well is one
thing. Exporting health carewhich it also didto what could well be
considered a developing country in the 1930s and beyond is quite
another. The scale on which this was done, the people who were key
participants, the consequences for all those employees and their
families associated with Aramco, and how Aramco s Medical Department
provided services to the non-Aramco population of Saudi Arabia s Eastern
Province seemed to be the ideal ingredients of an exciting story. Who
could best tell this tale? The people who contributed so much in
developing and extending Aramco s health care services.
Such a narrative required significant financial support.
Ultimately, it was possible to obtain a generous grant from the
donations committee of Saudi Aramco in Dhahran, Saudi Arabia, and after
engaging The Bancroft Library and those who were destined to be
contributors to this oral history collection, the project got underway.
But it wasn t until late 1995 and early 1996 that the interviews began.
Conservation of support funds was essential to bring the project along;
and with this in mind, my Bancroft Library historian, Carole Hicke, and
I decided to conduct interviews on a regional basis. It turned out that
there were important concentrations of former Aramco Medical Department
people in the New England, Puget Sound, and San Francisco Bay areas. We
planned to obtain interviews from fourteen key people. We came away
with twelve direct interviews, one telephone interview, and one written
contribution. As this is being written, editing is underway on the last
of the oral histories. And during the summer of 1997, we received a
financial supplement to our original grant from Saudi Aramco to bring
this project to its completion.
We feel fortunate to have had the cooperation and interest from
those -who made such vital contributions to Aramco s health care
programs. But most of all, we are grateful for their oral histories.
They tell of exotic diseases, hands-on care from dedicated doctors and
nurses, creative and imaginative corporate administration, health care
services which breached language and cultural barriers, lasting
friendships, and cutting-edge medical research. I feel privileged to
ii
have been a member of Aramco s health care team. Both Carole Hicke and
I feel even more fortunate to have been able to put this project
together for The Bancroft Library s Regional Oral History Office, for
Saudi Aramco, and for those readers who--we hopewill recognize the
scholarship with which we have tried to invest this work. We regret
only that circumstances of geography and limited finances prevented us
from obtaining and including interviews from others who made memorable
contributions to the Aramco and Saudi Aramco health care programs.
Aramco Health CareBeginnings and Evolution
It all began in 1936, with the arrival of T. C. Alexander, M.D.,
in Saudi Arabia. He was assigned to Dhahran as medical support for
drilling operations being conducted by the California-Arabian Standard
Oil Company (CASOC) . This company was formed by Standard Oil Company of
California (SOCAL), which ultimately became Chevron, Inc. Alexander s
clinic was the first in the region and the first in the field for an
American oil company operating in Saudi Arabia. This operation lacked a
hospital; so cases needing hospitalization were sent to Bahrain Island,
about twenty miles offshore. Among his other accomplishments, Dr.
Alexander started to train young Saudi men as nursing assistants. Some
of them were sent to Beirut for additional instruction as dental
hygienists and dental technicians. The main medical problems
confronting Alexander at this time were endemic communicable diseases
such as malaria, trachoma, smallpox, and tuberculosis.
In 1937, families from the U.S. began to arrive in Dhahran, as the
local workforce steadily expanded. During the World War II years, three
more physicians were recruited, and wards were added to the existing
clinics. On the night of October 19, 1940, both Dhahran and Bahrain
were bombed by Italian planes; and subsequently, families were evacuated
until the end of World War II.
In 1944, CASOC became the Arabian American Oil Company (Aramco),
and the company opened a refinery in Ras Tanura together with clinic/
dispensaries in both Ras Tanura and adjacent Rahima. These were for
American and European expatriates (Ras Tanura) and for Saudi employees
and their families (Rahima) .
American families began to return in 1945, and by 1948 Aramco was
operating clinics, infirmaries, a pharmacy, and hospitalswith a total
bed capacity of 205--scattered throughout the areas of oil production.
By this time Aramco s corporate structure included four owner companies:
SOCAL, Standard Oil of New Jersey later to become Exxon- -Texaco, and
Mobil. In 1949, Aramco began to add more hospital beds to its existing
clinic facilities. The epidemiology of malaria in the Eastern Province
was being explored and a malaria control program was underway.
iii
In 1955 a collaborative research project on trachoma was
established between Aramco s Medical Department and the Harvard School
of Public Health. And in 1956 a hospital/clinic complex, Dhahran Health
Center (DHC), was completed and opened as a secondary care facility for
major surgery, isolation, intensive medical care, sophisticated
laboratory and imaging services, field-wide medical administration, a
base for preventive medicine and public health outreach, and for
outpatient care. The same year, similarthough much smaller-
facilities were opened in both Ras Tanura and Abqaiq, and their older
units were closed. The Preventive Medicine Division at DHC started a
program of tuberculosis case finding and control, maternal-child health
clinics had been established, and health education projects were being
developed.
In 1957, Aramco s Medical Department hired its first industrial
hygienist, and by 1963 had its first occupational health physician.
Preventive and curative medicine had entered upon a unique partnership
whichtogether with its projects in medical researchwould become the
hallmark of Aramco s health care program.
Endemic Diseases
Despite the fact that Saudi Arabia was changing rapidly from a
developing country into a nation which would resemble the technocracies
of the West, the profile of disease was more representative of many
third-world countries during the 1960s. And while there was an
efflorescence of both private and government health care programs and
facilities within the Kingdom, information on health demographics was
lacking except as an extrapolation of epidemiologic data gathered by
Araraco. But at this time, Aramco had been collecting extensive data on
the incidence /prevalence of malaria and trachoma in the Eastern Province
and on schistosomiasis elsewhere in the Kingdom. Large-scale
epidemiologic investigations on conjunctivitis generally, and on
trachoma in particular, were launched in 1955 as the first stage in the
research project launched by the Aramco /Harvard collaborators.
Beginning in 1947, the Saudi government had developed a
cooperative malaria surveillance program with Aramco in the Eastern
Province. And control measures had started in 1948, primarily through
an extensive residual spraying campaign utilizing DDT. There was an
immediate and dramatic reduction in the incidence of malariaboth among
employees and among villagers in outlying oases which were being
monitored with annual malaria surveys. Resistance to DDT was
encountered in 1953, and Dieldrin was introduced for residual spraying
in 195*5 . By 1956, the Saudi government had taken the initiative for
malaria control in the Eastern Province. And this, together with the
more effective Dieldrin spraying, left malaria as a vanishing disease.
IV
A program of smallpox eradication had been undertaken in the late
1950s by the Saudi government, and this disease soon disappeared from
the Eastern Province. Tuberculosis remained an endemic problem. But
with effective case finding- -through x-ray screening and skin testing-
early treatment with an arsenal of effective drugs, and meticulous
outpatient followup, it appeared that Saudis could expect the same
satisfying results from modern treatment as Europeans or Americans.
Although Saudi Arabia s Eastern Province was not an endemic area
for schistosomiasis, the disease was rather common among Aramco
employeesmany of whom had come from the central and western regions of
the Kingdom. In contrast to infected patients from other populations in
the Middle East, the majority of Saudis seemed to have mild disease with
few symptoms. In 1965, a team from Aramco s Preventive Medicine
Division initiated a large-scale epidemiologic survey of sixty-seven
communities scattered throughout the Kingdom. Hundreds of individuals
were examined for evidence of diseaseemphasis being on identification
of schistosome eggs in the stool and/or urineand scores of water
sources were examined for evidence of the snail vectors which transmit
this infection. What emerged from this investigation was a monograph,
published as a limited, paperback edition in 1967. It remains unmatched
as the most extensive and complete study of its kind ever carried out in
Saudi Arabia. 1 It also remains relatively inaccessible, despite its
importance as a point of reference for the most widespread previous and
subsequent surveys. The most important results from this study were:
there are two schistosomal worms represented in the Kingdom. S. mansoni
is by far the most prevalent and is transmitted from many sources along
the watershed on the eastern side of the great mountain chain which
roughly parallels the coastline of the Red Sea. S. hematobium is
confined to the western watershed of the same range. The Eastern
Province is free of endemic disease and of snail vectors.
Another helminth infection of some importance was ascariasis.
Generally regarded as relatively asymptomatic, it can sometimes be
complicated by intestinal obstruction because of excessive numbers of
parasites in the gut. But in Saudi Arabia there was an additional
complication: seasonal pneumonitis due to pulmonary larval migration.
This was exclusively a disease of Saudis, characteristically occurring
each spring, usually several weeks after the brief, annual rainy season.
Transmission was seasonallimited to winter and spring because of the
intense daytime temperatures during the rest of the year, which
prevented survival of helminth ova.
1 Alio, Ivan. The Epidemiology of Schistosomiasis in Saudi Arabia
with an Emphasis on Geographic Distribution Patterns. Riyadh, Saudi
Arabia: University Press, 1967.
During the spring months there was also a recurring flu-like
illness--Q fever--among Americans and other expatriates living in Aramco
communities. This infection was presumably transmitted during the
lambing/kidding season by infectious aerosols from products of
conception within the herds of goats and sheep tended by the local
Bedouin. What wasn t appreciated at the time was that Q fever is one of
the most communicable of all infections the inhalation of just a few
organisms being enough to produce infection, sometimes illness. Which
is why the organism, Coxiella burnetti, has been considered a candidate
for biological warfare.
Trachoma was hyperendemic in the oases of Saudi Arabia s Eastern
Province, with prevalence as high as 90 percent in some communities.
The Harvard /Aramco research project was concerned with the clinical
aspects, the epidemiology, and the prevention of trachoma. Ultimately
epidemiological patterns emerged which indicated that trachoma was
essentially a family disease, and that it was most prevalent in the most
primitive and isolated oasis villages. Wherever trachoma was
encountered, prevalence and severity could be correlated with the level
of socioeconomic development and of sanitation. With prosperity and
improvements in hygiene, clinical trachoma was less evident, and other
indices of infection less apparent.
During the decade of the 1960s, the trachoma research program
became the centerpiece for Aramco 1 s research efforts as the disease
itself began to yield to the pressures of economic development and
social change. To speed up this favorable trend, a field trial of
immunization was carried out on almost 5,000 subjectswith both
disappointing and inconclusive results. But the thrust of the program
was to accumulate information on the epidemiology of the disease in
Saudi Arabia, which would be of help in developing control measures, not
only for the Kingdom, but for adjacent countries with endemic trachoma
having similar climatic and social conditions. It is therefore somewhat
ironic that in a 1976 comprehensive review of trachoma control in the
Eastern Mediterranean, which contained data from several Middle East
countries, there is not even one citation from the many publications by
the Harvard /Aramco group. And the project is not even mentioned in the
text. 1
Viral hepatitis was common in the Saudi population and was
associated with high mortality among pregnant and recently delivered
women. This phenomenon had been observed in Africa, other parts of the
Middle East, and in an earlier, widespread epidemic in India. Although
the specific viral agent could not be identified in the Saudi cases at
the time, there is good reason to believe this infection was due to the
1 Majcuk, J. Trachoma control in the Eastern Mediterranean region.
WHO Chronicle 30: 97-100, 1967.
vi
hepatitis E virusbased on more recent experience with infections due
to this agent and on the sere-epidemiology of hepatitis E.
There is more to the story of communicable disease: the interviews
in this series will mention some diseases included in this introduction.
But some merit comment here. Typhoid reached a peak in 1956, with
eighty-four cases reported in Aramco facilities for the year.
Thereafter, there was a steady decline. Bacterial dysentery (Shigella
infections) remained a significant endemic problem throughout the 1960s
and 1970s with rates up to 50 per 10,000 population. Poliomyelitis was
still present in the local population, and in 1973 there were ten
reported cases of paralytic disease reported from Aramco medical
facilities. The incidence of sexually transmitted disease increased
through the 1970s, with gonococcal infection most often reported.
Tetanus was an endemic problem in the Saudi population at all
ages, but mostly among the newborn. It seemed clear that neonatal
tetanus was due to infection through contamination of the umbilicus
shortly after birth. But among adults and children, the site of entry
for viable tetanus organisms was often inapparent. With the advent of
immunization programs --and thereby an emerging population of immune
mothersneonatal tetanus virtually disappeared among Aramco s Saudi
newborns, and became a vanishing infection among children and adults for
the same reasons.
Measles and chicken pox remained vexing problems among Aramco s
Saudi dependent children. And it was not until measles immunization
became as widely available in Saudi Arabia as it was in Europe and the
United States that the former disease began to decline significantly.
Diarrheal disease, primarily in infants and children, was always a
significant medical problem during the early years of Aramco s health
care program. Hospitalizations steadily increased from 1956 to 1966,
after which there was a steady decline through 197 A and beyond.
Mortality from diarrheal disease, which peaked in 1962--prior to a steep
rise in hospital admissions for this problemdeclined rapidly, but
ahead of the decline in morbidity. In most cases, the disease agent
could not be identified, but Shigella species accounted for most of the
bacterial isolates from stool samples.
Although there had been isolated reports of the disease cutaneous
leishmaniasis (Oriental sore, Baghdad boil) from the Arabian peninsula
before and during Aramco s early years, it was not until the 1970s that
this condition reached epidemic proportions. Beginning with six cases
in 1970, there was an explosive increase in the disease occurring among
Aramco s Saudi employees and dependents with a reported total of 542
vii
cases by the end of 1979. From the beginning, it was apparent that the
majority of patients were from the large al-Hasa oasis; of these, 73
percent were under the age of fifteen years, with both sexes equally
represented.
Reports of cutaneous leishmaniasis (CL) in widely separated areas
of the Kingdom began to appear in published reports from sources outside
of Aramco s Medical Department. For example, in a little more than a
two-year period, it was possible to collect data on 726 cases of the
disease referred to medical facilities in an area adjacent to Saudi
Arabia s capital, Riyadh. 2 The clinical features of these cases were
quite similar to those encountered among affected individuals reported
to Aramco from al-Hasa--including a predilection for the extremities and
the presence of multiple lesions in the same individual. In two key
publications which described CL in a colony of European expatriates
residing and working near Hofuf (al-Hasa oasis), both the clinical
features and epidemiological clues suggested that the organism was L.
tropica major, that P. papatasi (sandfly) was the vector, and that
certain desert rodents (Meriones libycus and Meriones crassus) were the
most likely natural hosts. 3i * Looking back on the Aramco experience with
CL, it appears that there was a distinct seasonal pattern to disease
outbreaks, with the largest proportion of cases presenting in the months
of December into March.
The central issue in the evolution of CL in Saudi Arabia during
the 1970s and 1980s appeared to be the ecology of this disease in
relation to the dramatic social change and economic development which
characterized this period. There were rapid population shifts,
accelerated suburban development, and vast building projects which
served to increase human contact with the sandfly vector. In addition,
or alternatively, these conditions may have created an enrichment
phenomenoneither by propagation of the CL parasites within the rodent
population, an increase in the rodent population, or both. It was
1 Aramco Medical Department: Epidemiological Bulletin 1-4, Jun-Jul,
1976; 1-7, Jan-Mar, 1980.
2 Morsy, T.A. Oriental Sore in Riyadh, Saudi Arabia. Castellania
3: 155-157, 1975.
3 Bienzle, U., Ebert, F., and Dietrich, M. Cutaneous leishmaniasis
in Eastern Saudi Arabia. Epidemiological and clinical features in a
non- immune population living in an endemic area. Tropenmed. Parasit.
29: 188-193, 1978.
4 Buttiker, W. , and Lous, D. J. Ecological studies in Hofuf,
eastern Saudi Arabia, in relation to dermal leishmaniasis. Tropenmed.
Parasit 30: 220-229, 1979.
viii
difficult to test these hypotheses under conditions of continuing
environmental change.
Another possibility is that widespread residual spraying for
malaria in townsites of the Eastern Province had earlier decimated the
sandfly population, thus interrupting transmission of CL. But residual
spraying was to a great extent abandoned and replaced by a larviciding
program in 1963 in the al-Hasa oasis, some eight years before the sharp
increase in the incidence of CL was observed. Publications on the
problem of cutaneous leishmaniasis in Saudi Arabia continue to appear
from various sources outside of Saudi Aramco s medical services.
It was during the late 1960s that several noninfectious diseases
attracted the attention of clinicians and researchers in Aramco s
Medical Department. It was known that the sickle cell trait was present
at a fairly high frequency within the oasis populations of the Eastern
Province. But sickle cell disease was not diagnosed nearly as often as
it should have been, simply because the disease was so mild in Saudis.
This was--and still is--in striking contrast to the character of the
disease in Africa and among African Americans. Studies on the
distribution, the unique clinical features, the genetics, and the
molecular biology of the condition in Saudis began with a collection of
patients encountered on routine visits or during hospitalization for
other, unrelated problems.
Ultimately these studies would involve a team of researchers from
Oxford, as well as Aramco clinicians and technical support in the
laboratories of Dhahran Health Center. Early revelations about the
expression of sickle cell disease in Saudis attracted the attention of
other workers in Saudi Arabia and elsewhere, leading to intense research
efforts, which still continue in the Kingdom. A byproduct of the
research on benign sickle cell disease in Saudis has been a greater
understanding of certain genetic f actorsother than the hemoglobin S
gene itselfwhich modify the expression of the disease, and
applications of this knowledge to develop new treatments for the more
severe, African-type disease.
Other genetic markers which affected red blood cells in Saudis,
particularly the oasis populations, are the thalassemias and glucose-6-
phosphate dehydrogenase (G6PD) deficiency. The Saudis have thalassemias
which suppress the production of both the alpha and beta hemoglobin
chains, producing a wide range of phenotypes with altered red cell
morphology, and a range of disease expression from the mildest anemia to
the more incapacitating, so-called thalassemia major. And of course
there is interaction with the sickle cell trait to produce genetic
admixture which also modifies the expression of sickle cell disease and
limits its severity.
ix
The type of G6PD deficiency encountered among Saudis is severe,
with almost complete absence of this red cell enzyme, which, among other
problems, can lead to abrupt and intense hemolysis in affected subjects
who ingest fava beans. The population genetics of this disorder have
been thoroughly worked out in Saudis, and this research has been
continued elsewhereagain, at other institutions in Saudi Arabia.
The unusual constellation of red cell genetic markers--G6PD
deficiency, the thalassemias, and hemoglobin S, together and separately
--are believed to confer considerable resistance to falciparum malaria,
and most likely have profoundly affected both the endemicity and
severity of this type of malaria in oasis populations. Finally, Saudis
--again, primarily within the oasis populationstend to lack the Duffy
blood group antigens, which function as receptors on the human red cell
for the Plasmodium vivax malarial parasite. Thus, the oasis Saudis have
a significant immunity against vivax malaria. The Duffy negative blood
group is an African genetic trait, shared to a lesser extent by Middle
East populations and Americans of African descent. This cluster of
genetic markers which confer resistance against two types of malaria is
unique to oasis Saudis and to native Africans.
Medical Miscellany
The usual cancers which characterize aging populations of the West
were less evident among the Saudis. In this group, lymphomas and
leukemias were the most common, followed by stomach cancer. And
typically, the lymphomas were of the non-Hodgkin 1 s type, often
presenting with abdominal disease, rather than with the peripheral or
mediastinal adenopathy usually associated with lymphomas among other
populations. It was difficult to distinguish abdominal lymphomas from
abdominal tuberculosisthe two so often presenting with similar signs
and symptoms. But by the mid- seventies, lung cancer was rapidly
overtaking leukemias and lymphomas in incidence, primarily among an
emerging, older, Saudi population.
What about degenerative diseases of middle age and beyond, which
seem to plague Western societies? Basically, Aramco s health care
program was involved with two rather distinct populations: a relatively
small number of American and European expatriates- -many with their young
families- -and a much larger group of primarily young Saudis. A
relatively small proportion of Saudi employees had families at that
time. The Americans and Europeans, as expected, experienced
hypertension, coronary artery disease, and three major cancers lung,
breast, and colon at about the same frequency and in the same age
stratification as might be observed in America or Europe. But by the
age of sixty, almost all of the expatriates had reached retirement and
were on their way back to points of origin. They had not even joined
the ranks of the "geriatric" population when they left Saudi Arabia.
Like retired military, most went on to other careers. And so prostate
cancer and stroke were uncommon.
The population of Western smokers was again what you might expect
--about 40 percentbefore that landmark announcement by the U.S.
Surgeon General in the 1960s. But Aramco s doctors were not seeing very
much tobacco smoking-related diseases chronic obstructive lung disease
and mouth cancers- -except for the emergence of lung cancer among aging
Saudis.
Now the question of alcoholism and its consequences. The Saudi
authorities strictly prohibit the importation and sale of alcoholic
beverages. And there is no question that consumption of alcohol by
Muslims is forbidden. Which left the issue of alcohol consumption by
non-Muslim foreigners somewhat ambiguous. As it turned out, Western
ingenuity and the Saudis kindly tolerance for Westerners made it
possible to produce and consume alcohol in privacy. Once again, this
was with the understanding that alcohol consumption would not take place
in Muslim company and would not be distributedeven as a gift to
Muslims .
Americans and others produced alcohol in the time-honored
tradition of fermentation, using yeast and some source of sugar, and
they went on to further refine and concentrate the product by a series
of distillations, which often resulted in a concentration of ethanol
approaching 95 percent. It would be safe to say that alcohol was
available in abundance to many people in Saudi Arabia s Eastern
Province.
Alcoholism, then, was a problem, but no more nor less than might
be expected in any expatriate community representing a slice of America.
Surprisingly, delirium tremens, acute alcoholic hallucinosis, alcoholic
neuropathy, liver disease, and cardiomyopathy were rare.
But Aramco s medical problems were by no means confined to exotic
diseases plus the usual degenerative diseases of Western society. As
originally conceived, Aramco s health care program would be primarily
concerned with employee health in an occupational setting. And in this
context, environmental health and industrial medicine were to be
important considerations.
As expected, in any large industrial undertaking- -either domestic
or foreign- -employees were exposed to a variety of hazards in the
workplace. And in an oil-producing area, with a subtropical-to-tropical
climate, there were health risks in oil exploration, production,
refining, storage, and transportation.
Surprisingly, heat exposure was less of a problem than
anticipated. To a large extent, heat exhaustion and heat stroke were
xi
prevented by attention to acclimatization, adequate water and salt
intake, early removal from exposure when symptoms or signs suggested
heat-related illness, and prompt supportive treatment for heat-related
casualties. Much of Aramco s administrative apparatus and its
personnel, community services, and medical care were housed in air-
conditioned environments. Americans and other Western expatriates
residing in Aramco communities were protected by residential air
conditioning. For those working both outside and in interior
environments in which air conditioning was lacking, every effort was
made to avoid dangerous exposure to high temperatures.
Despite an active safety program inaugurated early in Aramco s
history, there were a variety of job-related accidents and associated
trauma. Risky chemical exposures, such as those related directly to oil
production, were rare. As expected, poorly defined low back pain,
without a clear history of job-related, predisposing incident, was
fairly common. In later years, with increasing availability of auto
transportation, there were also more motor vehicle accidentswith
attendant trauma and occasional fatalities. In residential
environments, among Saudi dependents, there was a significant number of
burns from the use of gasoline-fueled stoves. Generally, this would
result from ignition of loose garments.
Deluxe Health Care: Psychiatric and Dental Services
It took a generation of employees and dependents some with
incipient, some with florid psychosis or neurosisbefore Aramco s
health care system began to deal with psychiatric illness by utilizing
professionals and facilities for psychiatric care at the Dhahran Health
Center. In its early years, psychiatric problems of any consequence
among expatriates were managed by referral to U.S. or European
facilities. Ultimately, and despite cultural barriers, it was
recognized that psychiatric disability was not uncommon among indigenous
peoples of the Middle East. And of course, Saudi Arabia was no
exception. As Aramco s Medical Department expanded in the 1970s, so did
the subspecialties of psychiatry and clinical psychology.
One of the brilliant chapters in the story of Aramco s health care
program is its history of dental care for expatriates and their
families, and eventually for the Saudi population under the wing of
Aramco s health care program. Ultimately, dental services included all
the subspecialties of surgery, restorative dentistry, endodontia,
periodontia, and orthodontia. Early on, dental care was incorporated
into the district outpatient services. Dental specialty services were
developed at Dhahran Health Center, and later as a large, free-standing
dental clinic adjacent to DHC with a full range of treatment and
preventive services.
xii
Dramatis Personae
Those who have contributed to this collection of oral histories
will tell stories which will deal with Aramco s health care program in
more detailhighlighting certain disease problems, medical research,
relationships with non-Aramco health care agencies and medical care
facilities, disease prevention, health care facility design and
construction, interaction with various parts of Aramco s administrative
elements, and personal experiences related to work and residence in
Saudi Arabia.
Three of the contributors to this series rose from the ranks to
become Aramco medical directors: Drs. Daggy, Handschin, and Taylor.
Three others rose to head Internal Medicine and the Medical Services
unit: Drs. Gelpi, Mustafa, and Perrine. Three others were intimately
involved in the trachoma research project sponsored by the Harvard
School of Public Health and supported by Aramco: Dr. John Snyder
(Harvard School of Public Health) , Elinor Nichols the widow of Roger
Nichols, field director of the project and Dorothy McComb, technologist
for the trachoma laboratory at Dhahran Health Center.
Dr. Bernard Eggerman, DOS, pioneered the development of Aramco s
comprehensive dental care program, integrating it with the medical
department s health care program. Virginia Dooling, RN, was key player
in the nursing serviceboth in hands-on nursing care and nursing
administration. Dr. Robert Oertley had several roles in Aramco s health
care operation: family practitioner, district medical director, and
epidemiologist. His wife, Pat, jointly contributed her experiences to
this collection. Dr. Ivor Morgan was Aramco s first obstetrician. Mr.
Gordon Flom was a prime mover in Aramco s medical facility renovations
and construction during the 1970s. Interestingly, there was almost
continuous interaction between our contributors both socially and
professionally during parts of three decades, spanning the mid-fifties
to the late seventies.
Besides anecdotal information on how they came to work in Aramco s
health care program, contributors elaborate on the many facets of health
careboth to Americans and to Saudis and their families and on life in
Saudi Arabia. We learn more about endemic malaria in the Eastern
Province and measures taken not only to control this disease but to
virtually eliminate it from oasis communities in which it was
holoendemic. There is more about trachoma: the disease, the village
surveys which mapped its epidemiology, about laboratory isolation of the
infectious agent, the use of a new screening technique fluorescent
antibody microscopy to identify and quantify the infectious agent in
scrapings from the inner eyelid surfaces, about the vaccine trial, and
about treatment and prevention.
Contributors elaborate on some of the clinical problems
encountered among American employees and their dependents, as well as
xiii
those which were more representative of the Saudi work force and Saudi
dependents. They repeatedly refer to the interaction between Aramco s
health care staff and the physicians and nursing staffs of those local
facilities outside of Aramco which were ultimately utilized for primary
care and routine hospitalization of Aramco employees and their
dependents .
They comment in some detail as to how the liaison between Aramco
and these "contract" facilities was established and sustained. And
contributors have much to say about relationships between the medical
staffs in Dhahran and the two districts: Ras Tanura and Abqaiq. There
is considerable commentary about the relationship between the Medical
Department, the company s Industrial Relations executives, and other
top-level management. There is talk about how Aramco s health care
program influenced the evolution of private and government health care
services in Saudi Arabia.
There is continual emphasis on professional standards,
accountability, quality assessment, periodic evaluation by the American
Joint Commission on Hospital Accreditation, and upon continuing medical
education. Contributors help us to understand how research on local
medical problems added to general medical knowledge as well as enabling
practitioners to use this knowledge in disease prevention and patient
care. There is material on hospital and facility construction brought
about by the rapid expansion of oil production, with corresponding
increases in the size of the work force and the numbers of dependents
eligible for health care.
We learn about the demographics of health and disease in eastern
Saudi Arabia, and how they were changed by Aramco s health care program.
We learn how Aramco s corporate structure affected administration in its
Medical Department. And we can trace a continuous thread of interaction
between preventive and curative services within Aramco s health care
program.
We can see how physicians, nurses, other technical staff, and
administrators were personally affected by their experiences with Saudis
and Saudi society, by life in Saudi Arabia, and by their new
understanding of Middle East cultures. And last of all, we learn
something about the destinies of those who left Aramco for other
professional pursuits back in the U.S.
It may seem strange that there is so little said about Aramco s
corporate change from its role as a creature of Mobil, Exxon, Texaco,
and Chevron to an oil company owned and operated by the Saudi
government. Officially, Aramco was nationalized on November 11, 1988.
But in fact, preparations had started in 1980, and there were gradual
changes in management structure throughout the company- -including the
Medical Department from that time until the corporate change became
xiv
official. The reason that little is made of this change by those
contributing to this oral history collection is simply that changing
Aramco s Medical Department to Saudi Aramco Medical Services
Organization (SAMSO) was gradual, smooth, and essentially uncomplicated.
In summary, this collection of oral histories is a record of
astonishing achievement in the provision of health care services to
employees and dependents of a major oil company operating in a harsh
environment and in a rapidly changing society and national economy. It
is the story of health services extended beyond employees and their
dependents, of health care provided to a needy general public before
government and entrepreneurial services were widely available. And it
is a story of major research efforts carried out on such diseases as
malaria, trachoma, sickle cell disease, and schistosomiasis . Here we
have an unparalleled, corporate accomplishment, not only in major
industry, but as a vast humanitarian effort in personalized health care,
disease prevention, health education, and biomedical research. No other
corporation has matched this joint endeavor of oil production and health
services either at home or abroad.
Acknowledgements
This collection would not have been possible without the splendid,
individual contributions from former members of Aramco and Saudi
Aramco s health care program. The essential financial support was
provided by Saudi Aramco s donations committee, both to get the project
underway (1995) and to keep it afloat (1997). Carole Hicke, oral
historian and colleague, from the Regional Oral History Office of The
Bancroft Library at the University of California, Berkeley, conducted
all of the interviews--more than forty hours worth of taped dialogue--
and collaborated with this editor/contributor to produce written, edited
transcripts, which form the bulk of this publication. My thanks goes
also to Willa Baum, director of the Regional Oral History Office, and to
Shannon Page, its office manager, and to other staff for their support
and interest. I am indebted to Saudi Aramco s Medical Services
Organization s Tarek M. Khattab, M.D., for some early historical
material about Aramco s Medical Department. This appeared in his essay,
"The Development of Medical Services in Saudi Aramco." And an
abbreviated version appeared in the August 25, 1993 issue of the Dhahran
publication The Arabian Sun. Last of all I want to thank Mr. Daniel
Blucker of Dhahran Health Center s medical library for a bibliography of
recent publications by SAMSO staff physicians and for photo-
illustrations of Aramco and Saudi Aramco health care facilities.
Armand P. Gelpi, M.D.
December 9, 1997
Sonoma, California
XV
VOLUME HISTORY
Aramco began producing oil in Saudi Arabia in 1938. Its name then
was California Arabian Standard Oil Company (Casoc), and it was owned by
Standard Oil Company of California (Socal) . King Abd al Aziz had
granted Socal the concession in 1933 to explore for and produce oil in
parts of Saudi Arabia, and the company finally encountered oil in
commercial quantities after five years of searching.
So began the annals of a unique corporate enterprise, unique
because of its size, its Arabian operations, and its close interaction
with the people of Saudi Arabia. Early leadership by company officers
such as Tom Barger and Cy Hardy fostered attitudes of pluralism and
respect for the Saudi culture. The Saudis, for their part, responded
with equal measure. Great efforts were made by the Americans to train
and promote Saudis, and great efforts were made by the Saudis to provide
for the needs of the oil company. Thus, cooperation became the keynote.
Aramco s interest in Arabia extended beyond the production of oil.
For example, the company used its resources to collect and preserve old
books and manuscripts concerning the history of the country. Railroads,
roads, electrification, natural gas recoveryall were added to the
company s accomplishments to the benefit of the local economy. Even
more singular, perhaps most remarkable of all, was the work of the
Aramco Medical Department in achieving unprecedented successes in the
research and treatment of local, tropical diseases, in local public
health programs, and in preventive medicine projects.
Why would a company owned by four giant American oil corporations
(Standard Oil, now Chevron, eventually brought in Mobil, Texaco, and
Exxon as owner /shareholders) provide crucial medical services to the
local economy of its offshore operations? Partly, it seems, because the
need, like the distant mountain to be climbed, "was there." Partly,
also, because the Americans and other expatriates were interested in
Saudi Arabia. And partly out of inevitability.
First there was the need for health care for the Americans. Paul
Arnot, who joined Aramco in 1938 as an engineer, recalled no company
clinic in existence. The nearest facility was at Bahrain. Clearly, it
was more efficient to establish a clinic in Dhahran.
As oil operations increased and numbers of employees rose, more
medical staff was hired, and services grew. Saudi employees were
covered, of course, but it became evident that their families needed
help also. As Frank Jungers, former chairman and CEO of Aramco,
explained, "We just tried to move in the direction of providing good
care and minimizing work force disruption."
xv i
New laboratory facilities were required, and this made possible
research into local tropical diseases, including a study of trachoma
jointly sponsored by Aramco and Harvard Medical School. Malaria was
prevalent, and local village people needed help; mosquito abatement
would clearly benefit both the people and the company. Further
expansion of oil production resulted in more employees and the need for
more and better medical facilities. Thus the growth of the Medical
Department, thoroughly documented in this volume of oral histories.
Its success was monumental. Take the preventive medicine program,
for example. Before the mosquito abatement effort was undertaken, a
quarter of the employees had at least one attack of malaria a year. By
1963, fewer than a dozen cases were acquired in the Eastern Province.
Further, in the 1940s and fifties, deaths from communicable diseases,
such a tuberculosis, pneumonia, smallpox, hepatitis, malaria, typhoid
and viruses, were common; in the 1960s, the death rate of employees from
these diseases dropped to zero. The maternal and child health program
was equally effective: in 1958, 250 of every 1,000 children died in
their first year of life. By 1966, the number was down to 30 of 1,000.
The oral histories in this volume encompass most of the post-World
War II decades, and continue through the building of new facilities
completed in the 1980s. By that time, company ownership had been vested
in the Saudis, who continued the work of the Medical Department.
An earlier volume of Aramco oral histories 1 contains interviews
with company management engineers, financial and legal officers,
geologists, and researchers, as well as top-level executives. A few
wives commented on life in Dhahran. Completed in 1995, this volume came
to the attention of Dr. Armand P. Gelpi, who was with Aramco in the
1960s. Dr. Gelpi was fervently interested in documenting the history of
the Medical Department, unequaled for its pioneering work on several
fronts: research in exotic diseases; establishment of local clinics; the
Harvard- funded study of trachoma; social and cultural interaction. Dr.
Gelpi, in consultation with staff at the Regional Oral History Office,
began planning the project and invited Saudi Aramco, as the company is
now named, to underwrite it. Company officers graciously agreed.
Dr. Gelpi located the interviewees and established contact with
them, smoothing the way for the interviews. He reviewed the
transcripts, wrote an introduction to each, and indexed them. His work
along the way has been indispensable, and we are inordinately grateful
to him for his interest and efforts. Many Saudis and expatriates from
other countries could have contributed significantly to this history,
American Perspectives of Aramco. the Saudi-Arabian Oil-Producing
Company. 1930s to 1980s. Regional Oral History Office, The Bancroft Library,
University of California, Berkeley, 1995.
xvii
but restraints of distance and travel put these out of our reach for the
present.
The Regional Oral History Office was established in 1954 to
augment through tape-recorded memoirs the Library s materials on the
history of California and the West. Copies of all interviews are
available for research use in The Bancroft Library and in the UCLA
Department of Special Collections. The office is under the direction of
Willa K. Baum, Division Head, and the administrative direction of
Charles B. Faulhaber, James D. Hart Director of The Bancroft Library,
University of California, Berkeley.
Carole Hicke, Interviewer /Editor
Regional Oral History Office
Berkeley, California
March 1998
xviii
Regional Oral History Office University of California
The Bancroft Library Berkeley, California
Aramco Medical Department Oral History Project
Richard H. Daggy, Ph.D., Dr. P.H.
PREVENTIVE MEDICINE IN SAUDI ARABIA, 1947-1964
An Interview Conducted by
Carole Hicke
in 1996
Copyright <D 1998 by The Regents of the University of California
Since 1954 the Regional Oral History Office has been interviewing leading
participants in or well-placed witnesses to major events in the development of
Northern California, the West, and the Nation. Oral history is a method of
collecting historical information through tape-recorded interviews between a
narrator with firsthand knowledge of historically significant events and a well-
informed interviewer, with the goal of preserving substantive additions to the
historical record. The tape recording is transcribed, lightly edited for
continuity and clarity, and reviewed by the interviewee. The corrected
manuscript is indexed, bound with photographs and illustrative materials, and
placed in The Bancroft Library at the University of California, Berkeley, and in
other research collections for scholarly use. Because it is primary material,
oral history is not intended to present the final, verified, or complete
narrative of events. It is a spoken account, offered by the interviewee in
response to questioning, and as such it is reflective, partisan, deeply involved,
and irreplaceable.
************************************
All uses of this manuscript are covered by a legal agreement
between The Regents of the University of California and Richard H.
Daggy dated April 21, 1996. The manuscript is thereby made
available for research purposes. All literary rights in the
manuscript, including the right to publish, are reserved to The
Bancroft Library of the University of California, Berkeley. No part
of the manuscript may be quoted for publication without the written
permission of the Director of The Bancroft Library of the University
of California, Berkeley.
Requests for permission to quote for publication should be
addressed to the Regional Oral History Office, 486 Library,
University of California, Berkeley 94720, and should include
identification of the specific passages to be quoted, anticipated
use of the passages, and identification of the user. The legal
agreement with Richard H. Daggy requires that he be notified of the
request and allowed thirty days in which to respond.
It is recommended that this oral history be cited as follows:
Interview with Richard Daggy, an oral
history conducted in 1996 by Carole Hicke
in "Health and Disease in Saudi Arabia:
The Aramco Experience, 1940s- 1990s, "
Regional Oral History Office, The Bancroft
Library, University of California,
Berkeley, 1998.
Copy no.
XIX
INTERVIEW WITH RICHARD DAGGY xviii
CONTENTS xix
INTRODUCTION by A. P. Gelpi, M.D. xx
INTERVIEW HISTORY by Carole Hicke xxi
BIOGRAPHICAL INFORMATION xxii
I BACKGROUND AND EDUCATION 1
II JOINING ARAMCO 2
Applying and Interviewing 2
Moving to Saudi Arabia 3
III ELIMINATING MALARIA IN SAUDI ARABIA 5
Identifying the Problem 5
Taking the Malaria Survey: A Ten-Year Study 6
Malaria Controls 8
Meeting the King 14
Other Preventive Medicine Programs 15
Smallpox 15
Looking for a Trachoma Vaccine 18
Public Health Program 18
IV WORK AFTER ARAMCO 23
Associate Dean, Harvard School of Public Health 23
University Associates 24
Some Statistics and Evident Changes 25
XX
INTRODUCTION to Richard Daggy, Ph.D.
One of the most important elements of Aramco s health care
programdating back to Aramco s early yearswas its medical
department s Division of Preventive Medicine. In terms of its scope of
activity and accomplishments, it was coequal with curative medicine, and
in this sense it filled a unique role in establishing standards for
sanitation, pest control, communicable disease prevention, and other
environmental safeguards for the company, its employees and dependents,
and the communities in which they resided. Dr. Daggy was one of
Aramco s medical pioneers, and in this role he rose to head Preventive
Medicine and eventually to guide the staff of the Medical Department as
its medical director. The importance of his studies on the epidemiology
of oasis malaria in Saudi Arabia and his efforts in establishing malaria
surveillance and control procedures for Aramco and the Kingdom cannot be
overstated .
Armand P. Gelpi, M.D.
December 9, 1997
Sonoma, California
XXI
INTERVIEW HISTORY- -Richard Daggy, Ph.D.
Dr. Richard Daggy joined Aramco in 1947 as medical entomologist.
Within two years he became superintendent of Preventive Medicine
Division, and from 1952-1960 he was chief of Preventive Medicine. From
1960-1964 he was Aramco s medical director. Daggy s work in eradicating
malaria has received the highest praise from other members of the
medical staff who were in Saudi Arabia. For example, Dr. Phil Gelpi
said: "I was able to see, in the eight-year period that I was in a full-
time position at Aramco [1959-1967], a very rapid decrease of malaria
infections in the Eastern Province. I don t think there is any question
that this is directly attributable to the Aramco program that was
initiated by Dr. Daggy and was eventually taken up by the Ministry of
Health." The importance of this program to Saudi Arabs cannot be
overstated.
Daggy began by taking a malaria survey in about fifteen villages
throughout the Eastern Province. Rounding up the children in each
villageand bribing them with fig newtons ! --Daggy and his cohorts took
blood samples and analyzed them for malaria parasites. In some places,
he found 90-95 percent were positive. He then undertook a program of
spraying in the villages, checking the effect every few weeks. Daggy
delineated the results of his ten-year study in a major article
published in The American Journal of Tropical Medicine and Hygiene in
1959.
Daggy was interviewed in his country home near New Boston, New
Hampshire on April 21, 1996. His son, Hormoz Soheili, prepared a
delicious lunch, which we ate on an outdoor balcony overlooking woods, a
stream, and a bird feeder with many visitors.
Daggy contributed further to the project by underwriting lodging
expenses for my trip to Boston to interview him and other members of the
Aramco Medical Department.
The transcript was reviewed by interviewer and editor; few changes
were made.
Carole Hicke
Project Director
January 1997
Regional Oral History Office
University of California, Berkeley
xxii
Curriculum Vitae
RICHARD HENRY DAGGY, Ph.D., Dr.P.H.
RETIRED
Born: August 23, 1914, St. Paul, Minnesota
Marital Status: Single
Citizen: U.S.A.
Academic Training:
Dates
1934
1938
1941
1952,
1958
1960
Institution
University of Minnesota
University of Minnesota
University of Minnesota
Harvard University
Harvard University
Columbia University-
Program in Executive
Management, School of
Business Administration
Degree
S.B. (with distinction)
S.M.
Ph.D.
M.P.H. (magna cum laude)
Dr.P.H.
Certificate
Positions Held;
Dates
1939-1941
1942-1944
1944-1945
1945-1947
1947-1949
1949-1952
1952-1960
Position
Instructor in Biology
Ensign to Lt. (H-Vs)
Entomologist
Associate Entomologist
Associate Professor of
Entomology
Medical Entomologist
Superintendent
Preventive Medicine
Coordinator & Assistant
to the Medical Director
Name of Institution or Agency
Bemidji State College,
Bemidji, Minnesota
USNR
Malaria Control Unit,
South Pacific-New
Hebrides
Naval Medical School,
Bethesda, Maryland
University of Minnesota
Arabian American Oil Co.
Dhahran, Saudi Arabia
Preventive Medicine Division
Arabian American Oil Co.
Arabian American Oil Co.
xxiii
Positions Held (Continued)
Dates
Position
1960-1964
1954-1952
1962-1964
1964-1966
1965-1966
1966-1973
1968-1970
1969 (Nov.)-
1970 (May)
1971-1972
1964-1982
Medical Director
Visiting Lecturer on
Entomology
Visiting Lecturer on
Tropical Public Health
Assistant Dean for Inter
national Programs, and
Lecturer on Tropical
Public Health
Acting Head, Department of
Public Health Practice
Associate Dean for Inter
national Programs,
Faculty Advisor for
International Students,
& Lecturer on Tropical
Public Health
Acting Head, Department of
Microbiology
Acting Dean, Faculty of
Public Health
Acting Dean, Faculty of
Public Health
Lecturer on Tropical
Name of Institution or Agency
Arabian American Oil Co.
Harvard School of Public Health
Harvard School of Public Health
Harvard School of Public Health
Harvard School of Public Health
Harvard School of Public Health
Harvard School of Public Health
Harvard School of Public Health
Harvard School of Public Health
Harvard School of Public Health
Public Health (retired June 1982)
Membership in Professional Societies:
American Association for the Advancement of Science
American Public Health Association (Fellow)
American Society of Tropical Medicine and Hygiene
Delta Omega (National Honorary Society in Public Health)
Entomological Society of America
Explorers Club
Massachusetts Public Health Association
Royal Society for Tropical Medicine and Hygiene (Fellow)
Sigma Xi (National Scientific Honorary Society)
Society for International Development
World Affairs Council (Boston)
xx iv
Other:
Member, Advisory Committee, Development Advisory Service, Center for
International Studies, Harvard University, 1965-
Associate Director, Aramco Trachoma Research Program, 1959-1964
Member, Program Area Committee on International Health, American
Public Health Association, 1967-
Liaison Officer, International Fellowship Programs, Association of
American Medical Colleges, 1968-
Member, Committee on Instruction, Harvard University, 1968-
Selected Publications:
Daggy, R.H., Muegge, A., and Riley, W.A.: A preliminary study of the anopheline
mosquito fauna of southeastern Minnesota and adjacent Wisconsin areas.
Pub. Hlth. Reps. 56: 883-895, 1941.
Daggy, R.Ek : Aedes scutellaris hebrideus Edwards: a probable vector of dengue in
the New Hebrides. War. Med., 6: 292-293, 1944.
Daggy, R.H.: The biology and seasonal cycle of Anopheles farauti on Espiritu Santo,
New Hebrides. Ann. Ent. Soc. Am., 38: 1-13, 1945.
Daggy, R.H.: New species and previously undescribed naiads of some Minnesota
mayflies (Ephemeroptera) . Ann. Ent. Soc. Am., 38: 373-396, 1945.
Daggy, R.H.: So You ve Had Malaria. USPHS, Office of Malaria Control in War Areas,
Atlanta, Georgia, 22 pp., 1945 (processed).
Daggy, R.H.: The Extended Malaria Control Program. USPHS, Office of Malaria Control
in War Areas, Atlanta, Georgia, 28 pp., 1945 (processed).
Daggy, R.H.: A pictorial key to adult anophelines of the United States. USPHS,
Office of Malaria Control in War Areas, Atlanta, Georgia, 1945 (processed).
Daggy, R.H.: Handbook of Residual Spray Operations. USPHS, Office of Malaria Control
in War Areas, Atlanta, Georgia, 45 pp., 1945 (processed).
Daggy, R.H., Hodson, A.C., and Granovsky, A. A. : Recommendations for using DDT.
Univ. Minn. Agric. Ext. Bull., 252 (16 pp.), 1946.
Daggy, R.H., and Page, R.C.: Aramco s preventive medicine program. The Medical
Bulletin, 16: 196-204, 1956. Standard Oil Co. (N.J.), New York, N.Y.
Daggy, R.H.: Oasis Malaria. Industry and Tropical Health, 111: 42-55, 1957.
Harvard School of Public Health, Boston.
Daggy, R.H.: Malariometric evidence for DDT resistance in Anopheles Stephens! in
oases of Eastern Saudi Arabia. Proc. 6th International Congresses, Tropical
Medicine and Malaria. Vol. VII, Div. B. Malaria, 317-324, 1958.
Daggy, R.H. : Malaria in Oases of Eastern Saudi Arabia. Am. J. Trop. Med. and Hyg.,
8: 223-291, 1959.
Snyder, J.C., Page, R.C., Murray, E.S., Daggy, R.H., Bell, S.D., Jr., Nichols, R.L.,
Haddad, N.A., Hanna, A.T., and McComb, D.E.: Observations on the etiology of
trachoma. Am. J. Ophth., 48: 325-329, 1959.
Daggy, R.H.: The administration of medical care and health services by Aramco in
Saudi ^Arabia. The Medical Bulletin, 64: 1-23, 1964. Standard Oil Co. (N.J.),
New York, N.Y.
I BACKGROUND AND EDUCATION
[Interview 1: April 21, 1996 ]////
Hicke:. I d like to start this morning by asking you when and where you
were born.
Daggy: St. Paul, Minnesota, August 23, 1914.
Hicke: And did you grow up in St. Paul?
Daggy: I did.
Hicke: Where did you go to school?
Daggy: I went to high school and the University of Minnesota.
Hicke: At the university, what was your major?
Daggy: My original major was zoology, biology. I m Bachelor of Science,
I took a Master of Science and Doctoral Philosophy degree in
medical entomology.
Hicke: You got the Doctor of Philosophy, and then you also got another
degree, I believe.
Daggy: At Harvard, yes, years later.
Hicke: What was that degree in?
Daggy: Practical public health.
This symbol (#//) indicates that a tape or tape segment has begun or
ended. A guide to the tapes follows the transcript.
II JOINING ARAMCO
Applying and Interviewing
Hicke: After you got your Doctor of Philosophy, you were doing various
things, but let me ask you when you first started to get
interested in Aramco.
Daggy: Oh, after the war, in 1947, I guess. I had returned to the
University of Minnesota to be on the staff, but I was not
particularly interested in agricultural entomology. I was
interested primarily in medical entomologymalaria control, that
kind of thing. I had explored various opportunities in South
America and Venezuela, and then I got a phone call from an old
malaria control buddy [whom I had known] in the South Pacific who
asked if I was interested in Aramco.
Hicke: Who was this, what was his name?
Daggy: Dr. [Robert] Page. He died some years ago.
Hicke: Can you tell me anything about him?
Daggy: No, he was at the Texas Company primarily.
Hicke: Texaco?
Daggy: Texaco, and then he later came to Arabia, much after I did.
Hicke: I believe that was 1948. Did they interview you?
Daggy: Yes, I sort of interviewed them. I wrote them and said I was a
little puzzled as to why malaria could be such a big problem in
Saudi Arabia. I thought it was nothing more than a sea of sand.
Hicke:
That was my first reaction when I heard about it too.
Daggy: Exactly. I was puzzled as to why a good, self-respecting malaria
mosquito could make its way in Saudi Arabia. They said that
they d like to interview me in New York. I agreed, but I felt it
was kind of a waste of time. Malaria and Saudi Arabia didn t seem
to go together very well. When I arrived, they put me up in New
York at the hotel, and I soon found out in talking to them that
there was indeed a malaria problem, and I was interested in it. I
had reason to think that I would have plenty of chances to go to
Venezuela, to South America, but I would never get a chance to go
to Arabia, I thought. This was a new area and a big opportunity
for me, and I found myself agreeing to go and signing up.
Hicke: As what?
Daggy: As entomologist.
Hicke: Do you recall who interviewed you in New York?
Daggy: Dr. Page was one of them; he was associate medical director of the
Texas Company at the time. The Texas Company did some of the
recruiting for Aramco at that time. I don t remember the name of
the medical director as such. This would have been 1946, maybe
47. Dr. Robert C. Page was the distinctive one; he later became
medical director of Aramco and a close friend of mine.
Moving to Saudi Arabia
Hicke: So then did you move to Saudi Arabia?
Daggy: Yes. I recall getting on a plane and flying to London. The
British had done some work on malaria control in Palestine and the
Middle East. So I stopped at the London School of Tropical
Medicine to see what I could find out about malaria in that part
of the world. Then I flew on from London and I very vividly
remember flying into Malta. In those days you put down overnight,
you didn t fly at night, and we put down in Malta for the night.
I can remember vividly in the next morning flying over the North
African desert battlefield, the Rommel area. And then I flew on
to Cairo, and joined the Aramco plane- -they had their own plane in
those days. I joined the Aramco flight in Cairo, took off across
the Red Sea, and once I got across the Arabian Peninsula I
thought: My God, what have I done? What have I done?
Hicke: Was this looking down on it or when you got out of the plane?
Daggy: No, looking down on the whole countryside. It was just all sand,
it looked like to me. When I got to the Dhahran airport- -the
Dhahran airport in those days was kind of a corrugated tin shack.
I can remember having to walk over a kind of sand dune to get into
the corrugated iron building, and again I thought: What have I
done, what have I done?
Hicke: What time of year was this?
Daggy: This was about June 7th, early June, 1947. The hot season had
just begun, and the shamal, the wind, was blowing. It was not
showing Saudi Arabia at its best. I was met by someone at the
plane and taken to accommodations in a dormitory.
Hicke: You lived in a dormitory?
Daggy: ~ Well, a dormitory room. I was very lucky; most of the people were
in shared quarters. We had eight menwhat we called an eight-man
bunkhouse, two to a room. But I had a private room, in sort of an
exclusive area, special bachelor guest house, that was it.
Hicke: How did you rate that?
Daggy: My position, I guess.
Hicke: I see. Was there an entomologist there before you?
Daggy: No, there had never been any entomologist.
Ill ELIMINATING MALARIA IN SAUDI ARABIA
Identifying the Problem
Hicke: Do you know whosomebody in management said this is a big
problem, we need an entomologist?
Daggy: Well, they recognized that Aramco had the problem, not in the
American population because that was in the Dhahran compound.
Apparently the King, Abd al- Aziz, the unifier of Saudi Arabia,
had heard or learned something about the marvels of DDT in malaria
control. And he asked Aramco to look into it.
Aramco also had some part of the problem, especially in
their Saudi Arab employees and their Saudi Arab dependents. But
not in the American community. The camp was located in a non-
mosquito zone in--
Hicke: It was in a dry area.
Daggy: In a dry area, no oases.
Hicke: I guess we should clarify this; as I understand it, the mosquitos
were mostly in the oases.
Daggy: The mosquito breeding was occurring in the oases. I should
probably break off for a moment here. Since before biblical
times, the Arabs on the coast had a series of artesian wells,
flowing wells, all up and down the coast. My idea of an oasis, of
course, was a little pool of water and three strategically placed
palm trees, and that was it.
t
Hicke: Mine too.
Daggy: To my surprise, 1 found that some of the areas around oases were
extremely large, fifteen and twenty villages, large towns and
maybe fifty to hundred thousand people, all up and down the coast.
People were concentrated in the villages and in the oases, and the
mosquitos were all concentrated, of course, in the springs and the
water-bearing areas. And of course, malaria had existed there
from time immemorial to the present.
Hicke: Did they understand that mosquitos were causing it?
Daggy: No, no, I don t think so. Some of them may have, but most of them
did not. The ordinary local farmer did not. The population was
primarily divided into two groups: The Bedouin, who lived out in
the desert, and the so-called "Sown," who were the farmers. They
raised dates and winter vegetables, alfalfa for their animals, and
so on. The Aramco towns were in the desert, and they were far
away from any mosquitos or malaria in that sense.
Hicke: Were the employees, some of them, still living in these villages
in the oases?
Daggy: Yes, some of them, and sometimes, especially in the malaria
season, they would come down with malaria. A headman or a foreman
would come down with malaria, and then the rest of them would not
have any direction. Some of the men would get it too, of course,
but it would be particularly difficult when the Saudi foremen or
Saudi headmen were down with malaria. There were some deaths
among the Saudi employees, but not very many. If they were going
to die, they died as children. The malaria was very, very intense
in these areas.
Hicke: So are you saying they developed some sort of resistance?
Daggy: Well, some immunity; there were relatively few deaths among the
adults. Among the children of employees, dependents, there was
probably a high death rate. For example, you would find that a
woman may have seven or eight children, and only one or two would
have survived, or even less. She would indicate that the fever
got them. That was probably not entirely malaria, but probably to
a large degree due to malaria. So it was having a greater impact
on the children than on the adults, and that was one of the keys
that we used to measure malaria in the area.
Takine the Malaria Survey; A Ten-Year Study
Hicke: Tell me what you started out doing. Well, first of all, where
were your offices?
Daggy: We had an office in one of these portable bunkhouses at first. My
first job was to begin to get out in the fields and take a malaria
survey. I found these pictures to show you. [points to picture]
This is the way we d round up kids in the village.
Hicke: You had some people helping you?
Daggy: We d round up kids in the local village square, and then bribe
them by giving them fig newtons for a drop of blood. We d stab
them, take a blood smear, and take the slides back to the
laboratory and examine them for malaria parasites. We did this in
quite a few villages. The first year we covered about thirteen,
fourteen villages, and then second year we went to a nearby oasis,
Hofuf oasis, and did that as well.
Hicke: f Do you have any idea how many samples you took?
Daggy: Oh, this was done over a ten-year period, so there would be
thousands .
Hicke: What s this? [points to pamphlet] Is this one of your writings?
Daggy: Yes, that s the ten-year study, the major study on malaria. 1
Hicke: Did you spend all your time taking these samples in the villages?
Daggy: No, no, this was seasonal. Usually in the fall for a few weeks,
during the worst part of the malaria season, we d take samples
from the children and calculate the percentage positive for
malaria parasites. Then we d calculate the percentage of
positives in that village and get a general estimate of the amount
of malaria in that village. Some places it would be 90, 95
percent of the children running around with these parasites, and
no telling how many would have been sick and probably died of
infection. But that was a benchmark against which we could
measure the amount of malaria in the area, and that would be also
a benchmark against which we could measure the success of our
control measures.
Richard H. Daggy, "Malaria in Oases of Eastern Saudi Arabia," The
American Journal of Tropical Medicine and Hygiene, Vol. 8, No. 2 (part 2),
March 1959, 223-291.
Malaria Controls
Hicke: When did you start instituting controls?
Daggy: We had to wait for supplies. After the war I worked for the
Public Health Service on a DDT spray program in the South.
Malaria was present in the South, in the southern states,
particularly in the negro shacks and so on, very poor people. We
sprayed the inside of the tar paper shacks against the malaria
mosquitos.
I should point out the theory behind this. DDT was a
wartime discovery. It had been touted as a malaria control
measure because of its long-lasting effects in houses. You d take
a house like this and spray the walls and the ceilings and all the
rooms in the house, and you d lay a thin coating of DDT. You
probably wouldn t even be able to see it on a white wall, for
example, but it would remain there for a varying length of time.
We found out that in Saudi Arabia, because of the dry climate and
so on, you put on the spray coating of DDT in the early fall and
it would last for almost a year until the next season, which was
quite different from in more humid climates where you had to
reapply the spray at different intervals. We found out that we
could spray once a year. I don t whether you want to get this yet
or not. So once we got all our equipment in--
Hicke: Is this your equipment in this picture?
Daggy: Yes, we had crews like this going.
Hicke: That was for the spraying.
Daggy: Yes, spraying the walls and the ceilings. They were mainly palm
thatch huts. You might as well pull these pictures out first to
get an idea of what the place is like. That gave us a base for
measuring malaria. The theory was: after the spray was put on,
the mosquitos would rest on the walls and the ceilings during the
day and then come out at night to feed. Screens were unknown,
obviously, and people slept outdoors very seldom, because there
was no protection against mosquitos as such.
The malaria mosquitos don t annoy; they re not like other
mosquitos, buzzing around and making a noise and biting. You
don t know that you re being bitten actually, it s a nonpainful
bite, for the most part. And then filled up with blood, the
mosquitos would find a stable or a barn or a house to rest on the
walls. In some places I remember, it was almost as if you took a
handful of wet raisins and threw them against the wall and they d
all stick to the wall. They d be hanging onto the wall.
That was the cause of their downfall, because they would
absorb the DDT through their feet and be killed, and if they
weren t killed the first night they would be killed on the second
or third or fourth or fifth. It usually takes about two weeks for
the malaria parasite to mature and to be passed on to another
person by a bite, so you had about two weeksten days to two
weeksto get at the mosquitos if you didn t get them the first
night. But usually they would be killed in the houses, and that
was the focus of the malaria attack.
Hicke: Did the people object to having you come in and spray?
Daggy: -/ Well, sometimes. These were mainly shacks, pretty much. As soon
as they saw it was a means to be safe, they didn t object.
Actually, they didn t have any right to object. The governor had
absolute power.
Hicke: Oh I see. You had the support of their local sheik or amir?
Daggy: For the most part they wouldn t object, although if they had a
particularly nice house they might. But they soon found out that
all the spiders and flies and scorpions and things like that would
be killed by the same DDT spray. Most of them didn t connect the
mosquito control with malaria control; they relished the idea of
having their house fly-free and tick-free and scorpion-free right
away, but I m sure most of them didn t connect the mosquito death
with the drop in malaria.
Hicke: Since the king had interested himself, did you have to report to
the government?
Daggy: No, they let us do the whole works ourselves. An agreement was
made whereby they were supposed to have put up the money for the
DDT supplies, because it was going out to a public health program
in the villages and not in the company towns. Sometimes they
would not pay up on time, or they couldn t pay their billsit was
quite a bit later that they had all the money but they came
around.
Hicke: Did you have other Americans working with you and some Saudis?
Daggy: 1 had one American assistant, that s probably who you saw in the
picture.
Hicke: What was his name, can you recall?
10
Daggy: Don Strait. Then we had some of these Arab boys that you saw here
in the picture. We had headmen who would be gang pushers,
foremen- -
Hicke: You had the headmen and then you had the people that sprayed?
Daggy: Yes, the spray workers and so on. Spray crew. And then during
the malaria survey season, we had some of our American laboratory
technicians, who would come out and do the village finger sticking
for us. They enjoyed the chance to get out into the villages. It
was a kind of holiday for them, in a sense. And of course it only
took a few days.
Hicke: After you sprayed most of the places in a village, then would you
go back?
Daggy: Then I would go back and count the mosquitos on the wall. I soon
found out that they had almost entirely disappeared. I had
regular checkpoints which I visited every few weeks in various
villages. I soon found out that at first, compared to how it had
been before spraying, with these raisins on the wall, there were
just absolutely none resting on the walls, for a time. And then a
very few would begin to reappear toward the end of summer, just
before it was time to spray again. So we would repeat the cycle.
We would repeat the cycle, both as far as blood checks and the DDT
spray program, once every year for most of the ten years. And the
malaria rate dropped precipitously down to a couple percent,
compared to 97 percent of the kids.
Hicke: Obviously the Saudi employees were much better off but also all
the local population.
Daggy: The local population was better off and the effect on the children
was impressive; there were almost no deathswell, we had no way
of knowing about what the deaths in the villages were.
Hicke: That must have been very rewarding for you.
Daggy: Yes.
Hicke: Can you tell me some of the villages you visited, are the names
within reach? They re in that book.
Daggy: Damman, al-Khobar, Jubail, Dhahran, Abqaiq, Ras Tanura, Thuqbah,
Qatif, Saihat, Safwa, Tarut . And so on down the list.
11
Hicke: That s a lot. How long do you think it took, probably, over this
period of ten years before you saw this amazing change?
Daggy: Well, there were a series of changes. Occasionally, we would have
a problemthe government would refuse to pay its bill, or just
couldn t. So the company thought they would just have to draw the
line somewhere. We were going up and treating all the villages in
the area, which was not a responsibility of Aramco as such, and if
they weren t going to pay for it, so be it. So every once in a
while when they would stop spraying DDT, the mosquitos would come
back in the houses and again rest on the walls and bite the people
and so on. And then the malaria rate would go up.
I should interject here that all the mosquitos weren t being
killed, obviously, only the ones that were resting on the walls of
_j the houses, and those were the ones that were most likely to be
infected with the malaria parasite, and those were the ones which
were most likely to transmit it. So for the others, it had to be,
for the most part, repeated each year.
Ultimately you probably would cut down on the total number
of mosquitos that were infected, but you wouldn t know that unless
you dissected them and found out whether they were infected or
not.
Hicke: Are you telling me you didn t know how many were infected?
Daggy: You could count the numbers of mosquitos, as such, but that
doesn t mean that they were all infected or any of them were
infected. But obviously in the beginning a large number of them
were or you wouldn t have had the drop in malaria, or the increase
in malaria that happened when we skipped the year. It would go up
and down, up and down, every fall.
Hicke: So it would start to rise again, as you said, just before you were
ready to spray?
Daggy: When the first DDT was put on, the malaria rate dropped
precipitously, down, down, down, down, down.
Hicke: Oh yes. [Looking at a chart] Started in 47, and then actually by
1949 it had dropped hugely.
Daggy: That was the major, major drop. When they stopped doing spraying,
stopped buying DDT, we had to skip on certain years, and it was
almost an alternate year for a time. And that gave us a good
chance to really explore what was going on, although we didn t
like the idea of skipping a year and losing all that time. But we
gradually were able to cut down, even on an alternate-year basis,
12
Hicke:
Daggy:
Hicke :
Daggy:
Hicke:
Daggy;
Hicke:
Daggy:
Hicke :
Daggy:
on the number of infected mosquitos over the year, even by the
alternate spraying and nonspraying. Then later they got with it
and got the supplies coming through on a routine basis; so you
could plan, that way. You must remember that the supplies of DDT
had to be ordered about nine months in advance, for ocean
shipment .
Where did it come from?
Oh, I think most of it came from the U.S.
Now I understand you used some other things besides DDT?
Yes. Then we began to see a peculiar thing that occurred. The
DDT seemed not to be as effective against the mosquitos as it once
was. In other words the mosquitos were developing a resistance to
the poison; and that was observed all over the world by about the
same time I reported it to the World Health Organization in the
annual international meeting in India at that time.
We proved by malarial metric evidence that DDT was losing
its killing power against mosquitos, and they were becoming
resistant to it. We started another insecticide, Dieldrin. That
lasted for a couple of years, and pretty much replaced DDT in this
as well. And then towards the end of this study, Dieldrin was
becoming less effective.
Towards the end of the ten years?
Yes. That s about the time I left Arabia and some of the other
people took over, and then some of the World Health Organization
people took over the spray program, and the Saudi Arab government
took over some of it as well,
come to Harvard.
That s about the time I left to
I think it was Elinor [Nichols] who told me about the fish that
you threw into the wells. I think that s pretty novel. Can you
tell me about that?
There was some type of small fish in all the wells and streams in
the oasis, little, tiny fish, Gambusia.
About an inch long?
Yes, little, tiny things. So we moved some of those. They were
in the wells, and the wells would carry the water and the fish out
to the streams and to the irrigation ditches and so on. And
sometimes of course, the fish wouldn t cross over into the
drainage ditches. If the water was coming out like this and then
13
being absorbed over here, sometimes there wouldn t be a direct
connection with the water. We spread a lot of fish in there.
Then there was another oasis farther inland near Riyadh
which did not have any of these fish whatsoever; we never
discovered any of them. We moved some of them from the Qatif area
into the Riyadh area, from the coastal area into the inland area,
and dumped some of them intothere were a number of enormous, big
wells that pumped water out into the irrigation fields. We dumped
some of those fish into those wells and distributed them that way;
and then we distributed some of them in the drainage ditches as
well. As far as I know they re still in there.
Hicke: That s what Elinor was telling me; she said she went back with you
to one of those wells near Riyadh once. And you asked some boys
J that were diving into the well if the fish were still there, and
they said yes. But how did you know these fish werewhat were
they doing, eating the mosquitos?
Daggy: Yes. There were a lot of these f ish Gambusia is one that we use
in this country a lot little, tiny fish that grow no bigger than
that, being full grown. They feed on mosquito larvae almost
entirely.
Hicke: That was known?
Daggy: That s known all over the world.
Hicke: I see.
Daggy: I had introduced some of those into the New Hebrides during
malaria control work with the navy.
Hicke: Brought them from someplace else?
Daggy: Yes, I think we brought them from Australia or New Zealand, but
they re worldwide.
Hicke: Are there any anecdotes or stories that you recall in your travels
out to the villages in Saudi Arabia?
Daggy: Most of the houses in those days were very poor, thatched huts.
Foreigners normally didn t get into these. But when I was
inspecting some of the work to see if they were doing proper spray
application on the walls and ceilings, I remember an old woman who
didn t want to be taken out of the house; so they put a big basket
over her head and left her alone in the back while they sprayed
the roof and ceiling.
1A
Hicke : Did she survive?
Daggy: Oh yes, she survived, she had her wits, but she d probably never
seen an American before.
Hicke: Yes, sure.
Daggy: There were so many stories; I was there from 19A6 to 196A.
Hicke: Okay, well let s just keep that in mind as we go along, and if you
think of any, we ll include them. About two years after you were
there [19A9], you became the superintendent of the Preventive
Medicine Division; so did you have things other than malaria to
worry about then?
Daggy: The original charge was to do malaria control spraying entirely,
and as I told you, the malaria was not a problem in the company
towns. It was a program entirely in the villages, and obviously
most of the villagers did not work for the company, so the general
public derived most of the benefits from the spray program. Some
of the employees who worked for the company benefited, then some
of their children and wives and dependents benefited, but it was
primarily a program for the villages and the oases. And as I told
you before, the Aramco camps were not put in the villages
primarily for this reason. Well probably, not only for that
reason alone.
Hicke: Anyway, they were free of malaria.
Daggy: They were free, most of them never heard of malaria, never came in
contact with it.
Meeting the KingM
Hicke: Did you ever have any meetings with the king or any kind of
relationship with members of the court?
Daggy: Yes, actually we did visit the king once. In the early 1950s when
we first started the malaria program, "Abd al- Aziz knew about the
program and invited us to come and spray the palaces. They just
had mud brick houses then. And so we went to Riyadh and brought
our spray crew in. At that time you had to have permission of the
king to travel to Riyadh and if you did, you had to wear Arab
dress of course. The king sent a whole outfit to me of the robes,
which I wore, and I was invited to the majlis.
15
The drill was that you dressed in the Arab dress, and the
king was seated a on a low dais, surrounded by a line of guards
with embroidered cloaks, and we sat there and we chatted a bit,
through the interpreter of course. Then the king started hearing
petitions; and in the majlis, any subject might come before the
king with a petition to be heard and it would be granted or not
granted. During this period, Crown Prince Saud came forward to
kiss his father s hand, and he sat right at our feet on the floor.
We were sitting at the king s right hand; I was on a low chair,
and the crown prince came and sat at my feet, although swordsmen
and others were sitting on the floor also. So then we chatted a
while more and the audience was complete.
After that we worked in the palace for seven or eight days
spraying the rooms, and at that time I learned my first lesson in
-f slavery. The slaves there in the court were fat, well dressed,
usually black, and rather sassy; they were drinking coffee, and
the free men had to wait until they were ready to have their walls
sprayed.
Most of the lower quarters were animal quarters, camel
stables and so forth. I remember one occasion in Hofuf the camel
herder said that the amir wanted to have the camel stables sprayed
with DDT for ticks. They were like bedbugs, they were all over
everything. If you came in and stamped your feet on the ground,
it would sound like the camels and it d bring the ticks right out
of the ground. But the main spraying in Riyadh was for flies,
because the king wanted to see the effect on flies; they didn t
really have malaria mosquitos.
I was also called to Jiddah one time when there was an
outbreak of malaria up and down the coast, and we did a survey
along the coast where the African mosquitos had transmitted a
different kind of malaria, and at that time we met Faisal, who was
then viceroy of the Hijaz, later King Faisal. He was interested
in our work and he came to see what we were doing. So all in all,
I met three kings, Abd al- Aziz, Saud, and Faisal.
Other Preventive Medicine Programs// //
Smallpox
Hicke: Besides malaria, I believe you started other preventive medicine
programs?
16
Daggy: It started out that the medical director asked me to begin
preparing for other preventive medicine activity, public health
activity.
Hicke: Who was the medical director then?
Daggy: Well, I had several: Dr. [T.C.] Alexander was the one who was the
first director I d reported to when I came out. He was succeeded
by Dr. Page. And then Dr. Page left and I succeeded him. Dr.
[Richard] Handschin, did you talk to him by any chance?
Hicke: Not yet, but I m going to.
Daggy: Dr. Handschin then succeeded me when I came to Harvard, and Dr.--
Hicke: [Julius] Taylor was in there?
Daggy: Dr. Taylor came thereafter.
Hicke: Okay, and I interrupted you when you were just telling me that the
medical director asked you to--
Daggy: Yes, so he suggested that malaria was only one of the many, many,
many problems. Tuberculosis and trachoma, oh gosh, we had
smallpox outbreaks and things like that. I can remember one of
the cases: There was a pilgrimage up into Iraq I think it was; a
group of Muslims would go every year for the pilgrimage. This was
a good place of course to spread smallpox. So these pilgrims came
home to one of the small villages up near Ras Tanura, and we
learned that there was a possible outbreak of smallpox in this
small village. This had been one of the villages where we had
done some of our malaria work, so we were known to them, for we
had just done malaria work.
Hicke: This was Ras Tanura?
Daggy: Well, near Ras Tanura: Safwa. Apparently one of the children had
come down with smallpox en route from a pilgrimage site in Iraq,
had died en route, and they brought the body back into Safwa. But
then we heard there had been some additional cases of smallpox in
the area, and this is only fifteen, twenty miles away. I couldn t
imagine that they wouldn t have asked for help from the government
or from somebody for a smallpox epidemic! The world would be on
fire if we had smallpox around here.
I was asked to go up and investigate, because I had previous
experience with malaria control group. So I went up and sure
enough, I found I d see women on doorsteps cradling pock-marked
babies. Terrible, and of course it was being spread all over the
17
place. I ll never forget these blistered, black-faced babies; it
was amazing. I said, Oh well, it ll be simple enough. We ll get
a smallpox film: One of these films that had been made for the
pan-American audiences. They were for backward countries for
health education tools. I had arranged for one of these to be
sent out by air, I guess, and said, We ll take this film up and
put a sheet up in the town square, show the film on smallpox
control, and then we ll have a chance to talk to them about it,
and so on. I had planned all this, and I thought there could be
no possible objection to this.
So someone said, You re going to talk to the Government
Relations Department, are you not? The Government Relations
Department was in charge of all government contacts. They said,
We re not sure that you ll be allowed to do that. And I said, Of
--J course I will. (I was naive then.) If people are dying of
smallpox, you do what you can to prevent it. They said, Well,
you d better see the local governor about this.
So we did, and he said, No, there will be no health
education films shown on smallpox. If God had not wanted smallpox
visited on the population, he would not have sent it to the
population. All these educational films were verboten; he didn t
want just any kinds of films. The amir enjoyed war pictures and
battleship pictures. No entertainment film and no educational
film, nothing of this sort. I said, Oh my God, I can t believe
this!
Then we showed him this picture I guess of a film made in
South America. These were some Walt Disney films that were made
some time ago, years and years ago. We took these films up and
showed them, finally got permission to show them on the screen in
the village. Later we sent up a vaccination team for smallpox
vaccination, and then they got the epidemic under control.
I started to say that the film was not a big success,
because what these people were looking at were woods and streams-
like in South Americathe rivers and all the green, green grass,
and green trees and crops and so on; and of course they lived in a
sand pit really, in the middle of the desert, in a desert village.
Hicke: They couldn t relate to that.
Daggy: They couldn t relate to the rushing streams and lakes and pools
and so on, green grass and green trees and things like that; they
were looking at the background rather than the lesson of the
story.
**
18
Hicke : Were those the only cases of smallpox you saw?
Daggy: Yes, that was the last outbreak that we saw.
Hicke: Bill Taylor said he saw some.
Daggy: Yes.
Looking for a Trachoma Vaccine
Hicke: What other kinds of preventive health things did you do?
Daggy: Well, we tried to develop a vaccine for trachoma.
Hicke: Yes, Elinor told me a lot about that, so did Dotty McComb.
Daggy: Dr. Snyder--you ve got a kind of deposition from Snyder, I think;
did you see him?
Hicke: He sent some materials but I haven t gotten it yet; he sent it to
Phil [Gelpi] . But I know he has a lot to offer about that too.
Let me just ask you what you had to do with that project. Tell me
what you knew about it, from your own viewpoint.
Daggy: Well, I had little to do with the trachoma project except to ease
the way. I was medical director at that time, chief of Preventive
Medicine anyway. All that was a Harvard research program.
Hicke: I m interested to know exactly how it got started. I guess it got
started with Dr. Snyder coming out?
Daggy: Yes. I had gone to the Harvard School of Public Health to take a
Master of Public Health, because by that time [1952], as I was
telling you, some of this kind of work was going above and beyond
the malaria control project.
Public Health Program
Daggy: They asked me to head up a preventive medicine program, a public
health program.
Hicke: Aramco did?
19
Daggy: Aramco did.
Hicke: They didn t have one before?
Daggy: No, Aramco Medical Department soon found out that as they were
treating patients, the more they were treating them, the more they
got. There was no preventive program, no vaccination program for
the dependents; in those days you could hardly get a Saudi
employee into the hospital. In the early days he d avoid the
hospital like the plague; hospital was the place to die, like the
old times in this country.
I asked that I go to the Harvard School of Public Health for
a six-month period and then perhaps come back for my next biannual
visit to finish it up. So I went and took courses in maternal and
- child health and epidemiology and statistics, tropical public
health, tropical medicine, sanitary engineering, and things like
that. Then at the end, I fully expected to come back at midterm.
Dr. Ted Allen had been at the Harvard School of Public
Health at the end of the war. He suggested that I go there to the
School of Public Health, and then the dean, Dean Simmons, had been
an army chief of preventive medicine during the war, and he had
become dean of the School of Public Health a year or two before.
He talked to Dr. Allen on a visit, saying that he thought it would
be insane for me to leave in midterm and pick up two years later.
Ted Allen asked whether I would be willing to stay. Yes, of
course I would be willing to stay; but if I m gone for three or
four months and ask to stay nine, they can probably do without me
for quite a long time! [laughter] So I said, "Well you can ask
but I don t think it will do any good." And then after he was
gone, I thought, My gosh, this isenough s enough. I m asking to
stay at the School of Public Health for the rest of the semester?
If they can do without me this long, they can do without me for
good.
But to my great surprise, they put me on the stateside
payroll and told me to stay; and then I took the master of public
health at that time. That led to all the other public health
activities, preventive medicine activities of the time. We added
a health educator to the group; we added sanitary engineers; I got
another entomologist, epidemiologist, maternal and child health
specialists. We established the nucleus of a public health
program, actually, and then we began working on programs in
a ddition to malaria.
Some of those were not only for the Saudi employees but were
for some other kinds of preventive problems within the general
populace, Americans as well as local. They had quite a few
20
problems with amoebic dysentery, for example, infectious
hepatitis, a number of things. We had food and restaurant
programs. We had sanitarians, and we developed a small public
health program: health education, environmental health and
sanitation, --to prevent diarrhea, malnutrition, skin infections-
special care of premature infants.
I might give you this, I ve got an extra copy of this:
prenatal care, proper feeding for children, there s maternal child
health specialists and so on. 1
Hicke: I think we re going to deposit some papers in the library at
Berkeley to go along with the oral history, so if you have a copy
of that or any other papers that eventually we could have, that
would be excellent. Was it a fairly unusual thing for an offshore
corporation to develop this kind of program?
Daggy: I think it was an entirely new thing. I don t know of a single
similar case that has occurred.
Hicke: Do you have any sense of why Aramco?
Daggy: Well, yes. I think they had a sense of responsibility to their
employees, not only to their American employees but also to their
Saudi employees. And the Saudi employees for the most part lived
in the nearby villages; or if they came from a farther distant
area, they lived in the [Aramco] camps. Sometimes even in the
camp they would have to be brought in against their will because
they were sick. The dependents were of course in the villages.
For a time they did not come in for any kind of treatment; so
there was a big backlog of treatment in one of the most
undeveloped parts of the world.
Gradually it improved, with health education, with maternal
and child health assistance, with care, with nursing. This was
primarily a male-dominated area. Then some of the female
dependents and kids came in. The Saudi employees, their wives and
children, if they came in to the hospital, got treatment; but it
was rough getting them in, in the beginning. Soon the flood was
on, and you couldn t keep them out, in a sense. I once told
management that if this kept up, they were going to have a huge
medical department attached to a little oil company. It was
growing by leaps and bounds. We had about 12,000 Saudi employees,
and each one had one or two wives and a set of children. That
Richard H. Daggy and R.C. Page, "Aramco s Preventive Medicine
Program," The Medical Bulletin, 16: 196-204, 1956. Standard Oil Co.
(N.J.), New York, N.Y.
21
quickly added up: in addition to 3,000 Americans, we had 12-15,000
Saudi employees and 12-15,000 Saudis wives and kids. It was
overwhelming.
So we started out trying to work with the World Health
Organization and trying to get the Saudi Arab government, who had
begun to take some interest in the hospitals and the clinics, to
organize some preventive medicine programs in the towns and
villages nearby. Aramco could draw people in; but once all the
nonemployee dependents, as well as the employee dependents,
started coming inanyone could come in for medical care--so once
we had gotten to the point where the knowledge that medical care
was something that the employees learned to appreciate, then their
wives and families came to appreciate it. And then not only their
wives and families came in but everyone else came in for medical
y care. So that s when we started trying to point out that the
Saudi Arab government must take responsibility at least for their
own people.
Hicke: The people who weren t Aramco. .
Daggy: Those who weren t Aramco and had no association with Aramco.
Hicke: Was there somebody in the Aramco management that you think was
particularly supportive?
Daggy: Oh yes. I think Tom Barger was. He was a geologist who came out
originally, way back before my time; he is long since dead. Many
of these older employees had a very strong appreciation for the
Arab and for their character and culture. They were truly
appreciative; they had been on exploration parties, of course with
Arab guides in the exploration of Saudi Arabia; and they had
appreciated the men of the desert, if you will. I learned to
respect them and appreciate them. Those early explorers had a lot
of respect for the Arab. They tried to do what they could for
them. There was a whole big program of worker educationschools,
even grade schools in the villages. There was only one high
school in the whole area when I first came. Since then there have
been high schools and colleges and universities that have gone
ahead.
So there was a whole development program in addition to the
medical program: educational program, road development, urban
industrial development; they tried to get people started in
various businesses and so on.
Hicke: I don t want to keep you too much longer, but let me ask you if
there are some things that we haven t covered, that we should talk
22
f
about. Maybe you could tell me a bit about people you worked
with, like you had mentioned Dr. Mitch Owens.
Daggy: Yes. He was a health educator, and I think you d be able to get
more information from Dick Handschin; he may know where he is
located.
Hicke: When did he arrive and how did you get him?
Daggy: After I came back from the Harvard School of Public Health the
first time, with my master s degree in health education, I felt we
needed a health educator, and we hired one.
Hicke: He was in charge of programs?
Daggy: Yes, this describes his activities.
Hicke: The Administration of Medical Care and Health Services by Aramco
in Saudi Arabia, by Richard H. Daggy. 1 Was there anybody else that
you recall particularly that worked on this program?
Daggy: The Maternal and Child Health nurse, MCH nurse, and again
Handschin will be able to tell you about her. I can t even
remember her name. This was about the time I left.
From The Medical Bulletin, 64:1-23, March 1964. Standard Oil Co.
(N.J.) New York, N.Y.
23
IV WORK AFTER ARAMCO
Associate Dean, Harvard School of Public Health
Hicke: Well then, I d like to hear how you decided to leave and how you
wound things up, turned over the preventive health program to
somebody else.
Daggy: Well, I should tell you, I didn t want to leave.
Hicke: I think that s not unusual; a lot of people I ve talked to didn t
want to leave.
Daggy: I was kind of forced into it. Dean Snyder had assumed that I was
going to come at age fifty, taking early retirement.
Hicke: Come to Boston where he was?
Daggy: Come to Boston, yes, and take a post in the School of Public
Health as associate dean. I finally agreed to it. Remember I
think I told you that--
Hicke: You didn t tell me on the tape though. We were just talking when
we were having lunch, so I m asking you to repeat that story on
the tape. What you started to tell me at lunch was that every
time you saw him, he had said that--
Daggy: Yes, shortly before my fiftieth birthday, Dr. Snyder was out in
the field, and he had asked when I was coming back. I said I
didn t know and I wanted to stay at least until I was age fifty
and eligible for early retirement. I had no real reason for
coming back, and I thought he was interested in helping me get
relocated if I ever decided to come back. I indicated that I was
not going to come back at the earliest until age fifty, so that I
could be eligible for early retirement.
24
Hicke:
Daggy:
I didn t know at the time that he was thinking of a post at
Harvard, I just thought he was thinking in terms of a responsible
school looking for assignments of its graduates, someplace. When
I learned that he was thinking in terms of my coming to Harvard, I
was very surprised. I said, Well, I guess coming back to Harvard
University is no mean place to begin. So I had asked for a leave
of absence and then I d been home just about that time on
vacation, and I talked to my father about it. My father said, You
aren t going to hold up everyone along the chain of command, are
you, waiting a year while you can make up your mind? I thought
that was a strong way of putting it, but he was right. Dr.
Handschin would have been waiting a year just for me to make up my
mind, and other people were there. I decided that was not the
thing to do, and that if I was going to go, I should go, and if I
was going to stay, I should stay. When I finally decided, I
thanked the administration for their willingness to give me a
year s leave of absence, but I said, No, I ve got to make up my
mind. So then I came back to pick up the post at Harvard.
This is 64.
I retired in December 64. So then I came back, but I continued
my association with the Harvard-Aramco trachoma research team and
my interest in Saudi Arabia up to the present.
University Associates
Hicke:
Daggy:
Weren t you part of the University Associates?
me about your part in that too.
Maybe you can tell
Oh yes. Well, Dr. [Roger] Nichols thought it would be helpful to
Saudi Arabia to have a kind of a consultant group. He suggested
faculty members: the dean of the faculty at American University
of Beirut and the head of the Department of Tropical Public Health
at Johns Hopkins University and himself and myself at Harvard.
That was after I had retired from Harvard, partially retired
anyway, not active anymore. We went out to review and to make
recommendations on the long-term study, long-term project for the
Ministry of Health.
I had just built this house, and a friend of mine was
staying in it who had also been in Saudi Arabia. He had a heart
attack while living in the house with a friend, and I had to come
home; I had the dog and the house and everything else to take care
of. So I came home about that time. I prepared some of the
reports, but the main work was with Dr. Nichols and Elinor, Dotty
25
McComb, and that group. They had some additional programs in
Qatar, I think, in the Arabian peninsula, in addition to Saudi
Arabia, consultant activities. But I did not participate; my time
was cut short because I had to get back to the house.
II
Hicke: So that s it for University Associates?
Daggy: Yes, pretty much. Elinor would have told you more about that.
Hicke: Yes, she did tell me a lot.
Some Statistics and Evident Changes
Hicke: Okay, anything else that we should cover?
Daggy: I guess I can t think of anything. I ll probably think of
something as soon as you go. For example, we had 10,000 employees
and 9,000 wives, 29,000 kids in Saudi Arabia at that time.
Hicke: That s pretty impressive!
Daggy: These are all in here, these figuresthe general health status in
1949, 59, 69, 79, 89. Thirty years ago 10 percent had
physical defects, and 11 percent were unfit for employment; 87
percent underweight. Serious disease, intestinal worms, trachoma,
dysentery, malaria, tuberculosis.
Hicke: What about worms, did you do anything about worms?
Daggy: We tried to improve sanitary food and water supplies, health
education, that kind of thing. Oh, the Ministry of Health
Cooperative project--! told you that we attempted to get the
Ministry of Health to stand on its own two feet with the help of
the World Health Organization.
Hicke: You must have gotten them interested, because I know they built a
huge hospital and a lot of small hospitals even in outlying areas,
so I think you must have been convincing.
Daggy: This was about the time I left.
Hicke: I think we ve covered most of what I wanted to ask; it s been a
very informative interview, and I thank you very much.
26
Daggy: Well, you re most welcome.
Transcriber: Lisa Vasquez
Final Typists: Carolyn Rice, Shana Chen
27
Regional Oral History Office University of California
The Bancroft Library Berkeley, California
Aramco Medical Department Oral History Project
Armand P. Gelpi, M.D.
ARAMCO MEDICAL SERVICES: 1959-1969
Interviews Conducted by
Carole Hicke
in 1995 and 1996
Copyright 1998 by The Regents of the University of California
Since 1954 the Regional Oral History Office has been interviewing leading
participants in or well-placed witnesses to major events in the development of
Northern California, the West, and the Nation. Oral history is a method of
collecting historical information through tape-recorded interviews between a
narrator with firsthand knowledge of historically significant events and a well-
informed interviewer, with the goal of preserving substantive additions to the
historical record. The tape recording is transcribed, lightly edited for
continuity and clarity, and reviewed by the interviewee. The corrected
manuscript is indexed, bound with photographs and illustrative materials, and
placed in The Bancroft Library at the University of California, Berkeley, and in
other research collections for scholarly use. Because it is primary material,
oral history is not intended to present the final, verified, or complete
narrative of events. It is a spoken account, offered by the interviewee in
response to questioning, and as such it is reflective, partisan, deeply involved,
and irreplaceable.
************************************
All uses of this manuscript are covered by a legal agreement between
The Regents of the University of California and Armand P. Gelpi
dated February 16, 1996. The manuscript is thereby made available
for research purposes. All literary rights in the manuscript,
including the right to publish, are reserved to The Bancroft Library
of the University of California, Berkeley. No part of the
manuscript may be quoted for publication without the written
permission of the Director of The Bancroft Library of the University
of California, Berkeley.
Requests for permission to quote for publication should be addressed
to the Regional Oral History Office, 486 Library, University of
California, Berkeley 94720, and should include identification of the
specific passages to be quoted, anticipated use of the passages, and
identification of the user. The legal agreement with Armand P.
Gelpi requires that he be notified of the request and allowed thirty
days in which to respond.
It is recommended that this oral history be cited as follows:
Interview with Armand P. Gelpi, an oral
history conducted in 1996 by Carole Hicke
in "Health and Disease in Saudi Arabia:
The Aramco Experience, 1940s- 1990s,"
Regional Oral History Office, The Bancroft
Library, University of California,
Berkeley, 1998.
Copy no.
Armand P. Gelpi.
Photograph by Elson- Alexandra, Los Angeles
28
TABLE OF CONTENTS --Armand P. Gelpi, M.D.
CONTENTS 28
INTRODUCTION by A. P. Gelpi 30
INTERVIEW HISTORY 31
I BACKGROUND 33
Growing Up in Denver and California 33
Pre-med Training in the U.S. Navy, 1943-1945 34
Medical School 35
Internship and Military Service During the Korean War 37
Residency in San Francisco and San Jose, 1952-1955 40
Practicing Medicine in the V.A. Health Care System 41
Private Medical Practice 42
II EMPLOYMENT WITH ARAMCO, 1959 43
Job Interview 43
The Move to Dhahran, Saudi Arabia 45
Aramco Health Care in Saudi Arabia Before 1959 46
Aramco s Dhahran Health Center 47
Community Clinics 50
More About Dhahran Health Center 50
III FACILITIES AND PATIENTS 52
Contract Facilities 52
Trips to Qatar in 1960 and 1968 54
Health Care at DHC and Other Aramco Facilities: Patients 57
Community Life 58
Aramco Medicine 58
Aramco Provides Medical Services to the Royal Family 62
The Persian Gulf Medical Society and Aramco s Medical
Department 64
IV HEALTH AND DISEASE IN SAUDI ARABIA 67
Smallpox 67
Malaria 68
Aramco s Health Care Program and the Saudi Government 70
More about Aramco and Malaria Control 72
Trachoma and Aramco s Trachoma Research Project 73
Q Fever in Saudi Arabia 75
Pulmonary Ascariasis 79
Cancer 82
Conference in Shiraz, Iran: G6PD Deficiency and Favism 85
Sickle Cell Trait and Sickle Cell Disease 90
Schistosomiasis 96
Pulmonary Tuberculosis 98
Hepatitis 99
29
V MEDICAL DEPARTMENT ADMINISTRATION 103
Reporting to Aramco Management 103
Hiring 104
District Visits and Medical Education 107
More on the Journal Club 109
VI RESIGNATION AND RETURN VISITS TO DHAHRAN 111
Leaving Aramco 111
Medical Research in Dhahran, 1974-1978 112
30
INTRODUCTION- -Armand P. Gelpi, M.D.
Dr. Gelpi joined Aramco from a California private medical practice
in 1959 as a board-certified internist. Assigned to the medical staff
at Dhahran Health Center, he took over the newly created Medical
Services Unit composed of Internal Medicine, General Practice, and
Pediatrics. During his eight years of service as a full-time Aramco
employee in Saudi Arabia, he balanced his clinical activities with
medical research and administration. The years with Aramco, in Dhahran,
were enriching for Gelpi and his familyso much so that his son, Peter,
went back for a few years of employment with Aramco before heading to
business school. For the Gelpi family, where tennis and water sports
left off there was prospecting for archaeologic artifacts and travel to
other Middle East countries.
\j
Resigning from Aramco in 1969, after a year s sabbatical at
Stanford, Dr. Gelpi returned annually to Dhahran, beginning in 1974, to
complete research projects begun earlier. From 1974 through 1978 he
conducted summer research, mentoring college students in laboratory
technique and field epidemiology, and provided locum tenens support for
Internal Medicine. His last visit was in 1981, for clinical service
only.
His stateside medical career has spanned employment as assistant
medical director at the Stanford Student Health Service, faculty at
Stanford Medical Center, part-time staff at Palo Alto and Menlo Park VA
medical centers, and more recently, staff physician in occupational
health at the National Aerospace Administration s research center in
Mountain View, California. He and his wife Lou now live in Sonoma,
California .
Armand P. Gelpi, M.D.
December 9, 1997
Sonoma, California
31-32
INTERVIEW HISTORY--A. P. [Phil] Gelpi, M.D.
Dr. Phil Gelpi joined Aramco in 1959 as an internist and spent ten
years with the company in Saudi Arabia. Soon becoming chief of
medicine, he supervised the internal medicine, pediatrics, and general
practice services. This gave him both medical and administrative
duties, which he describes in detail. He discusses the village clinics
in Abqaiq and Ras Tanura, and the arrangements with contract hospitals,
which he supervised as liaison officer for Medical Services. His
patients, both Arab and American; other members of the diverse medical
staff; and relations with company management and with Saudi government
officials.
Dividing his time among his various duties proved to be a
considerable challenge--Gelpi estimates 25 percent of his time went to
administration, 25 percent to clinical practice, 25 percent to teaching,
and 25 percent to research. He instituted a medical journal club that
met regularly to review articles and exchange information.
Discussing his cases and diseases being treated, Gelpi covers
smallpox, malaria, trachoma, Q fever, pulmonary ascariasis, cancer,
sickle cell disease, schistosomiasis, tuberculosis, and hepatitis.
Gelpi was interviewed at his home in Sonoma, California, on
December 3, 1995, and January 2 and February 5, 1996. He had prepared
extensively with notes and written essays on his work in Saudi Arabia.
Instead of correcting the draft transcript, he chose to rewrite most of
it, thus producing a somewhat formal document but one offering much
information in a clear and concise manner.
Carole Hicke
Project Director
January 1997
Regional Oral History Office
University of California, Berkeley
33
I BACKGROUND
[Interview 1: December 3, 1995]
f
Growing Up in Denver and California
Hicke: Let me start this morning by asking when and where you were born,
and where you grew up.
Gelpi: I was born in Denver, Colorado, in 1925, grew up in Denver, and
moved with my mother to California in 1939. My father remained in
Denver.
Hicke: And you went to school there?
Gelpi: I started high school in La Jolla, a town in southern California
just north of San Diego. My mother and I remained two years in La
Jolla and then moved to Beverly Hills.
Hicke: What particular subjects did you like in high school?
Gelpi: I was interested in science and math primarily; but I think I had
a fairly balanced high school education. I was particularly
interested in chemistry, and actually considered becoming a
chemist at one point during high school. This changed with the
advent of World War II, when the opportunity appeared to enlist in
an officers training program offered by the navy for college
students who would ultimately serve as lawyers, doctors, and
supply officers in the navy.
34
Pre-med Training in the U.S. Navy. 1943-1945
Hicke: So you joined the navy?
Gelpi: I joined in 1943 and was sent to the University of Texas for both
military training and undergraduate college education in the V-12
program (similar to the army s officer s training program, and
today s ROTC) . I completed almost four years of college,
compressed into six semesters, spanning two years.
Hicke: You got college credit?
Gelpi: I got full college credit; and then for a brief period I was
assigned to a navy hospital in Norman, Oklahoma, pending my
admission to medical school, which turned out to be the University
of California Medical School in San Francisco.
Hicke: What kind of courses were you taking in the V-12 program?
Gelpi: Well, there was a standard pre-med curriculum, which is heavy on
science, not so heavy on math, and relatively weak on liberal
arts, but it turned out that there were enough electives so that I
got a fairly balanced liberal arts program. We had additional
navy training designed for officer candidates, which included
naval history, naval rules and regulations, military drill, daily
morning calisthenics, and an intensive additional program of
physical education for an hour a day, five days a week. It is the
sort of exacting program you might expect at Annapolis, the Air
Force Academy, or West Point.
Hicke:
Let me back up a little bit. When did you decide you wanted to be
a physician?
Gelpi: By my senior year in high school I had just about decided to be a
physician. I knew that I was not only interested in the science
of medicine, but it appeared that medicine offered me an
opportunity to deal with people as well as with ideas and issues.
So I ultimately decided that going into medicine would meet all my
objectives, including science and the need also to have some kind
of personal contacts in my work.
Hicke: Did any person inspire you?
Gelpi: Not really. My father was a dentist; but I never for a moment
considered going into dentistry. I had some uncles on my father s
side who were doctors, but I had virtually no contact with them.
So they really didn t influence me. My mother was probably more
influential than anyone, simply because she was looking at
35
medicine as an avenue to a comfortable income, social status, and
other benefits which seem to be acceptable reasons for parents to
propel their children into medicine and other professions.
Hicke: So then when you joined the navy you specifically requested a pre-
med program?
Gelpi: There were specific undergraduate programs for pre-meds,
engineers, officers destined for the supply corps, naval law, and
for naval aviation. The V-12 program included special training
for all those students who were not destined to become line
officers (those who would be involved in the operation of naval
vessels and/or combat activities) or navy pilots. There were
probably several thousands of young men in the V-12 program,
several hundred of whom were assigned to the University of Texas
^,in Austin, which had one of the largest officer training programs
in the country. Of course, the idea was to quickly build a pool
of officer specialists to meet the expanding needs of the navy
beyond the customary supply of career officers from Annapolis. At
the time the program was initiated, no one could have foreseen how
long the war would last and how much attrition there would be
among officers on active duty. So the navy planned to continue
their specialist officers training programs indefinitely.
Hicke: And when you went to the navy hospital in Norman, what were you
doing there?
Gelpi: I was a hospital corpsman. Corpsmen fulfilled a role that today
is shared by people like nurses assistants, paramedics,
physicians assistants, and emergency medical technicians, who are
attached to fire departments. The navy still has a place for
corpsmen, and presumably their duties are roughly the same.
Medical School
Hicke: And then you wanted to go to the University of California?
Gelpi: All of us who were waiting for admission to medical school as
officer candidates and those civilians enrolled in conventional
pre-med programs were ultimately brought before a "Deans
Committee," which as the name might suggest was made up of a panel
of deans from a number of medical schools throughout the country.
This panel would have reviewed the candidates curricula and grade
point average, and then following a half -hour interview make a
decision about eligibility for medical school. And based partly
upon the choices among medical schools expressed by the applicant,
36
the academic standing of each applicant, and the availability of
first-year slots within the pool of medical schools accepting
officer candidates, the applicant might get his first choice. I
was accepted at the University of California; and this happened to
be, for various reasons, my first choice.
Hicke: At the University of California, would you be still in the navy?
Gelpi: Still in the navy. We remained on active duty until the spring of
1946, that is, several months after the war ended. Once relieved
from active duty status in the military, we were obligated to
remain in the naval reserve- -which most of us did for several
years.
Hicke: When did you begin work at the University of California?
Gelpi: I started in September of 1945, graduating in July of 1949. Our
first year of medical school was in Berkeley, and the following
clinical years in San Francisco.
Hicke: When did you get married?
Gelpi: I married in 1952, during the Korean War while serving with the
U.S. Marine Corps as a naval medical officer.
Hicke: What is your wife s maiden name?
Gelpi: Lucille Dachos.
Hicke: Okay, back to medical school. Were there any particularly
memorable experiences that you had?
Gelpi: Yes, there were. I found the first year of school to be extremely
tedious and more difficult than I had anticipated. I had sailed
through the arduous premedical program at the University of Texas
and was not used to working as hard as I had to in order to obtain
acceptable grades in the first year of medical school. It wasn t
until my second year that I really became enthusiastic about
school. The first summer- -that is, between my freshman and
sophomore years--! spent in Austin, Texas, at the University of
Texas getting some extra liberal arts credits.
Hicke: Do medical students get much in the way of liberal arts courses?
Gelpi: Most of us felt deprived, particularly if we were involved in
accelerated programs of the sort offered by the navy, in which
science was emphasized at the expense of the humanities. And I
think nothing much has really changed. There is a lot of pious
deliberation among medical educators about a broad education for
37
today s physicians, but I think they are just blowing smoke rings.
The schools don t want a change. And of course pre-med students
are furiously competitive, trying to pile on as much science as
they can, and get the best grades, knowing that this will make the
difference between acceptance and rejection from the schools of
their choice.
Hicke: Then did you continue any of your interest in the liberal arts?
Obviously you didn t have time to do much.
Gelpi: I had really been stimulated by a couple of teachers at the
University of Texas. One taught a class in modern English
literature; the other offered a course in philosophy. I m still
quite interested in modern English literature, particularly the
world of short stories. I enjoy poetry. But 1 am perhaps most
.interested in expository writing in the areas of history,
politics, international relations, and economics.
Internship and Military Service During the Korean War
Hicke: What happened in 1949?
Gelpi: I graduated from medical school and interned at the Santa Clara
County Hospital in San Jose, California.
Hicke: Does anything stand out from that period?
Gelpi: This was a plunge from formal training into the real world of
"hands-on" medicine, and this was quite an experience. In those
days we had what is termed a rotating internship, which took the
medical school graduate through month-long practical rotations in
general medicine, pediatrics, obstetrics, gynecology, surgery, and
so on. The idea was to lay the foundation of broad clinical
experience, either for the generalist or the specialist, by
exposure to all of the specialties.
Hicke: When you say "generalist," do you mean a general practitioner?
Gelpi: Yes. But in the forties and fifties, surgeons, pediatricians,
internists, and specialists in obstetrics and gynecology were to a
certain extent generalists because these specialists had--and many
still have--a broad range of interests and clinical skills. It s
really only recently that subspecialties have proliferated to such
a great extent.
Hicke: What were you heading for?
38
Gelpi: I was definitely heading for internal medicine. As I progressed
through medical school, I found that I was more and more attracted
to this specialty. It seemed to me that internal medicine offered
the greatest opportunity for developing diagnostic skills and for
pursuing medical research. But I enjoyed pediatrics a lot as a
medical student, and was encouraged by the department chairman at
UCSF to take postgraduate training in pediatrics. But my first
love was, and still is, internal medicine, and so I sought a
residency in internal medicine.
Hicke: Did you say you spent a year in internship?
Gelpi: I spent a year, and then was called to active duty in the navy,
spending two years in military service. This was to pay my debt
to the U.S. government for V-12 training during World War II. I
spent two years as a navy medical officer, partly with the navy in
San Diego and partly with the marine corps at Camp Pendleton,
California, and at the marine corps cold weather training camp in
the eastern Sierras. My service in San Diego with the navy was at
the navy reception center for recruits.
Hicke: So at the reception center you were examining...?
Gelpi: I was examining reservists who had been called to active duty,
mostly for assignment to sea duty on ships supporting military
activities in Korea. For reasons which are unclear to me even
today, I eventually became psychiatrist for the receiving center
in San Diego.
Hicke: What did that involve?
Gelpi: To some extent, it involved trying to work with people who found
themselves rather upset by the prospects of being sent overseas
and exposed to combat conditions. In addition, my job included
evaluating enlisted men who had declared themselves to be
homosexual or who were thought to be homosexual by others, in
order to obtain psychiatric documentation of their sexual
orientation. I was supposed to have a close liaison with the
naval secret service, which, among its other tasks, was tracking
down suspected homosexuals. Homosexuals were then and today
believed to undermine moraleparticularly in close quarters,
under crowded conditions existing on board ships.
Hicke: I wanted to go back to one thing. You said you were interested in
the detective aspects of internal medicine, and I suspect that has
something to do with your research in Saudi Arabia. Am I right?
Gelpi: Well, eventually it did.
39
Hicke: I don t want to get into that right now. I just want to find out
how this interest grew.
Gelpi: It matured in Saudi Arabia.
Hicke: Yes, but did you develop that in your reading? Do you remember
how that started out?
Gelpi: In most medical schools, the role models for medical students are
not clinicians in the sense of people engaged in direct patient
care, but people who really have a career devoted to research,
teaching, or both. So this influences some medical school
graduates; and it certainly affected me to a certain extent, and
probably was in part responsible for my later interest in
research. But I was really torn between a career in community
^medical practice and clinical investigation. When I went to Saudi
Arabia, I was fortunate enough to do both--I thought, fairly well.
Hicke: Then when you were up at the cold weather training establishment
in the Sierras, what were you doing?
Gelpi: I was there for three months with a cold weather training
battalion. The program was designed by the marine corps to
prepare personnel for the rigors of Korea in the wintertime. We
were camped in a place where temperatures would often drop to ten
or twenty degrees below zero in midwintercomparable to what
troops might experience in Korea during the winter months. There
were casualties, not unexpected among unseasoned marines in a cold
weather environment. As a physician, I was at this camp to deal
with the usual medical needs of military personnel, but also with
injuries due to dampness and cold. We had a couple of near
disasters, but no deaths nor serious cold-induced injuries during
my tour of duty.
Hicke: Did you also participate in training troops to avoid the effects
of cold?
Gelpi: Sure. The idea was to teach the troops how to obtain the maximum
benefits from protective clothing, how to avoid excessive
exposure, and what to do with damp clothing in rapidly changing
temperatures. We wanted to teach the men the dangers of imbibing
alcohol under cold weather conditions, how to avoid frost-bite to
areas of the body which were necessarily exposed to the elements,
and how to avoid hypothermia.
a
Hicke: I m not sure what year we re up to now.
Gelpi: This would have been the winter of 1951 and early 1952.
40
Hicke: And then what happened?
Gelpi: I was discharged from the marine corps--
Hicke: Oh, you were in the marine corps?
Gelpi: I was attached to the marine corps as a navy doctor, and I was
actually discharged from the navy after two years of service in
the spring of 1952.
Residency in San Francisco and San Jose, 1952-1955
Hicke: Then what did you do?
Gelpi: I was preparing for my first year of residency in medicine and had
been accepted to the University of California, where I had applied
while still in the navy. We (my wife and I) moved to San
Francisco. I had a year s residency training under the auspices
of UCSF, which included rotations in college health and
experimental oncology. My second year s residency was spent
entirely at San Francisco General Hospital on the University of
California medical service.
Hicke: Were you still heading toward internal medicine?
Gelpi: All of my residency training was in preparation for internal
medicine. My last year of residency training was at Santa Clara
County Hospital--now the Santa Clara Valley Medical Centeras
chief medical resident. Interestingly, I shared this spot with
Dr. Richard Perrine--six months rotation for each of us leading
to a long professional and social relationship.
Hicke: Did you have something to do with his going to Saudi Arabia?
Gelpi: Actually, I did. He was interested, and made some inquiries
shortly after my arrival. I don t know how strongly I encouraged
him to join Aramco, but my encouragement may have been important
in his decision.
Hicke: When did you finish at Santa Clara County Hospital?
Gelpi: I finished in 1955; and at that point, I was toying with the idea
of going into private practice with one of the other physicians in
the San Jose Area. But I had also been recruited by UCLA s
Department of International Health to carry out a research project
on elephantiasis in Tahiti.
Hicke: What happened to that?
Gelpi: We had just had our second child, and my wife developed two
consecutive kidney infections. The prospects of going to Tahiti,
where I might be the only doctor in the particular area in which I
would have to work and would be without the necessary follow-up
medical care for my wife, made the UCLA offer less attractive. We
had actually purchased our steamship tickets in preparation for
departure; but in the end I had to decline the faculty appointment
with UCLA and the research assignment in Tahiti.
Practicing Medicine in the V.A. Health Care System
Hicke: What did you do instead?
Gelpi: I had to make some quick decisions about employment; and since I
had declined offers from local physicians for association and/or
partnership, I had to decide either on solo medical practice or
employment with a large medical group, such as existed at that
time both in government and the private sector. I selected the
Veterans Administration, for reasons which are not clear today,
and took a staff position with the V.A. medical center in Fresno,
California as a full-time, hospital-based internist.
Hicke: What did this involve?
Gelpi: It consisted of practicing as an internist, which is what I had
been trained for, in a well-equipped hospital which had about 200
beds. I remained in Fresno for a little less than two years, and
then transferred to the V.A. Medical Center in San Francisco,
where I had been offered a fellowship in oncology and hematology--
cancer and blood diseases.
Hicke: Were you doing research?
Gelpi: Mostly research, but my appointment also included some clinical
responsibilities, which provided additional training and
experience in the diagnosis and treatment of certain cancers and
blood diseases. I held this position for a little more than a
year.
Hicke: What year was this?
Gelpi: This would have been the years 1957-58. At the conclusion of the
fellowship I decided for various reasons to go into community
practice. On the other hand, I had been appointed, during the
fellowship, as a career clinical investigator with the Veterans
Administration. There was a conflict between me and the chief of
the medical service at the V.A. hospital which would have made it
difficult to carry on independent research and contribute to the
teaching program in oncology and hematology at San Francisco s
V.A. hospital. I was thus leaving a hostile environment and
entering private practice.
Private Medical Practice
Hicke: Where did that take you?
Gelpi: I went to San Leandro, California, on the invitation of two older
doctors who were looking for an eager, young associate. The
relationship was satisfactory, up to a point, and that was when I
found out that one of my associates was an alcoholic. I was
obliged to think seriously about a new association, or solo
practice. Fortunately a couple of local colleagues were quite
interested in having me, which would have made it easy to withdraw
from the short-term association in which I was established.
II EMPLOYMENT WITH ARAMCO, 1959
Job Interview
Gelpi: But then something unusual happened. One day I was scanning the
"wanted" pages of the Journal of the American Medical Association
and came across a notice that the Arabian American Oil Company was
seeking an internist for its he alth care program in Saudi Arabia.
At the time, I thought that maybe this would be a chance to become
more involved in international health, which had been my early
intention when I was considering the position with UCLA, and to
continue to practice medicine in my specialty. So I responded
with a letter, which I believe was addressed to Aramco s New York
of f ice--Aramco s U.S. headquarters at the time. I didn t get a
letter back; I got a phone call advising me that the director of
Aramco s medical services in Saudi Arabia just happened to be in
the U.S.A., and that he would be coming to San Francisco to
interview me. Thus began a long and fruitful relationship with
Aramco and its health care program.
Hicke: Tell me who interviewed you and how that went.
Gelpi: The medical director at that time was Dr. Robert Pagelong since
retired. The interview seemed to go well, and a few days later I
got a summons from the New York office saying they were interested
in employing me and advising me to get my affairs in order for an
early departure to Saudi Arabia.
Hicke: Oh, a job offer that soon?
Gelpi: Yes.
Hicke: What had they told you about your prospective duties?
Gelpi: They sketched out some of the responsibilities of the job, with
the implication that I would be doing pretty much what 1 had been
doing in the United States, that I would be able to work within my
specialty, and that I would be assigned to the main Aramco medical
facility in Dhahran. There I would be joining a group of mostly
American-trained doctors working at Dhahran Health Center.
However, I knew little about the range of diseases I would
encounter; but I knew I would be responsible for the medical care
of American and European expatriates and their families as well as
Saudis and expatriates from other Arab countries. I anticipated
certain diseases which would be expected in developing countries;
but here, there was uncertainty because of the very limited
published information on health and disease in Saudi Arabia.
Hicke: Had you been able to do any reading about diseases of Saudi
Arabia?
Gelpi: I found one relevant article published in the late fifties in a
journal of military medicine--a survey of diseases encountered in
Saudi Arabia s Eastern Province by a physician attached to the
U.S. military mission [United States Military Advisory Group]
stationed at Dhahran s airfield. There must have been others, but
I didn t know of early publications which might have revealed the
types of medical problems indigenous to Saudi Arabia. I presumed
that this was a country with plenty of tropical and other exotic
diseases. I was not to be disappointed.
But just to be reassured, I insisted on a visit to Dhahran
prior to my acceptance of the job offer by Aramco. This was an
unprecedented request. Nevertheless, the company agreed, and I
made my way to New York at my own expense, then to Dhahran on a
company aircraft. This was in the summer of 1959. I spent
several days in Saudi Arabia, and was not only able to tour the
medical facilities which existed at the time in Dhahran, but also
those in the clinics and inpatient facilities at Ras Tanura and
Abqaiq--about seventy-five miles north and south of Dhahran,
respectively. Perhaps the decisive part of this visit was an
excursion with Dr. Richard Daggy--then head of Preventive Medicine
in Dhahran--to one of the large villages in the Qatif oasis.
There I saw what I had hoped forsigns of such disease as malaria
and trachoma which affect the populations of so many developing
countries .
I had a better idea of what I was going to face in Saudi
Arabia, and this convinced me that Dhahran and its environs would
be good places to practice medicine. I was even more encouraged
by the knowledge that I would have a highly sophisticated back-up
system in the form of laboratories and imaging facilities of a
quality typical of many U.S. medical centers at that time, that I
would have colleagues trained in other specialties to work with.
That I would be on a medical frontier diagnosing and treating
45
tropical diseasesnot as a missionary doctor, but as a well-
trained internistwas an opportunity.
Hicke: How long did you spend in Dhahran on that trip?
Gelpi: Less than a week. But this was enough to convince me to close my
medical practice in San Leandro and move with my family to Saudi
Arabia. This I did in August of 1959, arriving in Dhahran without
my family, which would follow in December of the same year.
The Move to Dhahran, Saudi Arabia
Hicke: , You ve written a nice description of arriving at the airport in
Dhahran in which you said, "It was in late summer that I stepped
off a DC 6B airliner on the tarmacmelting, it seemed at Dhahran
airport. Temperatures at that time of year were said to reach
120oF in the afternoon, and this seemed to be one of those
afternoons. The airport terminal was simply an open shed for the
Saudi customs officials, with a pile of baggage in the center."
But what was the trip like? Yb u had very young children, I
believe.
Gelpi: I had left Lucille, my wife, with a lot of extra responsibility in
disposing of our home and automobiles, getting our personal
effects packed and off to Saudi Arabia by boat, and arranging for
tickets, passports, luggage, and a minimum of personal effects for
her to take to Saudi Arabia for our temporary housing in Dhahran.
Hicke: Did you fly in the Aramco plane?
Gelpi: For many years Aramco had its own fleet of airplanes, a couple of
which were turbo-prop aircraft which in most respects would be
equivalent to the commercial aircraft of that era making
international flights. On my second trip to Dhahran, I took a
commercial flight from San Francisco to New York; and then, after
an overnight hotel stay, I boarded Aramco s plane bound for
Dhahran. There was another overnight stop in Amsterdam, possibly
a fuel stop at Beirut, and then on to Dhahran.
Aramco Health Care in Saudi Arabia Before 1959
Hicke: Let me ask you, before we get started on your own activities
there, what you can remember hearing about Aramco s medical
department before your arrival.
Gelpi: There was a little anecdotal information, most of which I probably
soon forgot. At the time, I was looking towards the future--
perhaps less interested in the past than I should have been. I m
sure I was given a brief historical summary at the time of my
interview in San Francisco, maybe more when I arrived in Dhahran.
Hicke: You indicated off the record that you thought Dr. [T. C.]
Alexander was important. Was he still there when you arrived?
Gelpi: I believe that he was just about to retire when I arrived on my
first visit. I may have met him then, or a couple of months
later, when I made the final move to Saudi Arabia. I was told
that he was one of the first physicians to be assigned to Saudi
Arabia by Aramco. Actually, during my brief contact with him we
did talk some, but I don t remember the details of our
conversation. It turns out that he was one of the pioneers of
Aramco health care.
Hicke: I ve heard that the medical department was originally staffed by
Indian physicians. Were there any still there when you arrived?
Gelpi: There were many Indian physicians on the medical staff. Aside
from the Americans, they represented a majority. But in addition,
there was a handful of Lebanese and Palestinian physicians. There
were no Saudis until later.
Hicke: I suppose that the Indians spoke English and that was an
advantage. Why else would they have been recruited, do you think?
Gelpi: I don t know exactly why they were recruited in preference to
other expatriates, besides Americans. All spoke English; most
were from the Indian province of Goa, and most were Christian.
The significance of this is not clear but may have to do with the
compatibility between Islam and ChristianityChristians, with
Jews, being regarded as "people of the Book." And certainly
during the early years of Aramco s Medical Department,
employability to a certain extent was determined by stated
religious preference. There certainly must have been other
factors which brought Indian doctors to Saudi Arabia and Aramco.
There has long been a drain of highly trained professionals from
India because of adverse economic and social conditions; and
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Indian physicians were well represented in places like Africa, and
more recently in the United States.
I really think that Indian doctors were hoping for economic
gains and that the logistics of recruiting and moving Indian
physicians with their families to Saudi Arabia was more cost-
effective than relying on a staff which might be almost entirely
American and European. In any case, as far as religious
considerations are concerned, Aramco s expatriate employees were
either Christian or Muslim.
Hicke: But the Indian doctors were looking for something special with
Aramco?
Gelpi: They were looking for a better life and the immediate opportunity
~f of. having their families accompany them to a new home.
Aramco s Dhahran Health Center
Hicke: Okay, let s talk a little bit about what changes your life when
you got to Dhahran.
Gelpi: I was assigned to a hospital with clinical services a lot similar
to what I would expect in a community comparable in size to many
small towns in America. The difference was: here we had two
populations the Saudis, and expatriates from America, Europe, the
Middle East, and India.
Hicke: They were in separate camps?
Gelpi: To a great extent, depending on a number of factors including
nationality, cultural preferences, professional qualifications,
and social standards set by the Saudi government. Later, when the
Saudis were moving up the corporate ladder into increasingly
responsible positions, cultural and other arbitrary barriers which
separated Saudis from other employees and their families either
disappeared or were at least lowered.
Hicke: Wasn t there a separation of management and employees, rather than
simply separation of Saudis and Americans?
Gelpi: In part there was; but there was also definite social separation
based on culture, tradition, and religion. To a certain extent
this was promoted by the Saudi government, and possibly encouraged
by religious authorities. And there may have been some merit to
this separation, at least at first. I think that most of us
welcomed the idea of mixing freely with our Saudi hosts, but this
was not to befor a while. It was only later, in the sixties and
seventies, that there was a social transformationfelt at all
levels of the company and in Aramco communities which brought
Saudis and Americans closer together.
Hicke: Possibly at first the Saudis would not welcome an intrusion of
another culture?
Gelpi: Then, and possibly even today, the Saudis tenaciously held onto
"family values" and cultural standards which had been in place for
many generations. In spite of this, they were experiencing an
extraordinary cultural challenge because of increasing contact
with Westerners involved in oil exploration and oil production.
What we were witnessing was a society being propelled rapidly into
the 20th century a change taking place in a matter of years,
rather than centuries. And this has had some profound and lasting
effects on Saudi society. In the early days, there was a strong
fundamentalist element among the Saudi Muslim population, which
was and still is closely linked to government. This
relationship strongly affected government domestic and foreign
policy and still does. To some extent this relationship imposed
constraints on an earlier, closer social relationship between
Saudis and Americans. But on the whole, I believe that the Saudis
responded warmly to their American guests, acted as gracious
hosts, and moved at a pretty good clip into a more integrated
society.
Hicke: What was your hospital facility like?
Gelpi: As I mentioned earlier, I believe that Dhahran Health Center had
about 200 beds. It was modern in every respect, with air
conditioning, laboratory and x-ray services, and an up-to-date
surgical suite. This was a pleasant surprise, although I had
known about this from earlier reconnaissance.
Hicke: How about the staff?
Gelpi: I quickly got to know the staff members with whom I would be most
intimately associated in my day-to-day professional work. To
begin with these were members of Dhahran s Internal Medicine
service.
Hicke: You were in the Internal Medicine service, or you were heading it?
Gelpi: I didn t start as chief of Internal Medicine. A Dr. Les McCoy was
the chief when I arrived. And there were two other colleagues
Dr. Bill Weidman and Dr. Larry Field. Dr. McCoy remained chief
for a few months, but was then assigned to the clinic and
infirmary in the community of Abqaiq--an hour s auto ride south of
Dhahran. In a sense, I was serving as Dr. McCoy s replacement.
Early the following year we were joined by a physician from Egypt
--the name escapes me--who was recruited specifically to run our
tuberculosis inpatient service. At the time we had quite a few
Saudis with tuberculosis who were housed in a separate ward, and a
larger number who were being managed as outpatients.
Hicke: I read in your notes that this was primarily abdominal
tuberculosis .
Gelpi: -^We had primarily pulmonary tuberculosis. But abdominal
tuberculosis was surprisingly common- -certainly more common than
in the United States.
Hicke: I ve never even heard of it.
Gelpi: We thought then, and believe now, that the Saudis contracted their
tuberculosis through the usual respiratory route but that the
disease affected the abdominal organsmostly small bowel and
lymph nodesmore prominently than the lungs. There is also the
possibility that they contracted tuberculosis from animal sources.
There is a type of tuberculosis which specifically affects cattle
but which can be transmitted to humans by milk or milk products.
Saudis had access to plenty of camel and goat s milk. But the
first cattle were not imported into the Eastern Province of Saudi
Arabia until the early sixties; so it is unlikely that the Saudis
we saw with abdominal tuberculosis had the bovine type.
The common occurrence of abdominal tuberculosis is by no means
restricted to Saudi Arabia; there have been many reports of this
disease from a number of developing countries in Africa and the
Middle East. There may be something unique about either the
transmission of tuberculosis or host response in third-world
populations. In any case, regardless of whether one is dealing
with human or bovine tuberculosis, it is difficult to tell unless
one has rather refined laboratory testsnot always available in
the usual bacteriology lab. It may still be only of academic
interest, for the treatment available then and now was pretty
effective for the treatment of both human and bovine tuberculosis.
Hicke: Could camels carry bovine tuberculosis?
Gelpi: That s an interesting possibility, which we never explored.
50
Community Clinics
Hicke: Let s go back to when you arrived; there were two other Aramco
clinics besides the ones in Dhahran, right?
Gelpi: Yes, Abqaiq and Ras Tanura.
Hicke: Tell me about staffing at these clinics.
Gelpi: Each clinic had a permanent staff, and each of them had its own
infirmary for brief hospitalizations . People were placed in the
infirmary for observation for relatively mild illnesses not
requiring either elaborate diagnostic facilities, major surgery,
or intensive medical care. On occasion, we even confined patients
with mild heart attacks in these infirmaries. This was before the
days of coronary care units, sophisticated cardiac monitoring, and
advanced cardiopulmonary resuscitation.
Hicke: For the most part, anyone with a major medical problem who had to
be hospitalized would be sent to Dhahran?
Gelpi: Anyone with a serious problem had to be sent to Dhahran. Those
with, say, a mild pneumonia requiring only bed rest and
antibiotics could remain in one of the district infirmaries.
More About Dhahran Health Center
Hicke: Going back to the hospital in Dhahran, [William L.] Bill Owen, the
former general counsel of Aramco, described to me that the first
hospital was built in the senior management camp, and then there
was another medical facility built in the Arab camp, and there was
a tunnel between the two, and then eventually a new hospital was
built in the Dhahran camp. What was left of all that when you got
there?
Gelpi: Bill Owen was talking about the wooden frame buildings which
originally served as hospitals and clinics for Aramco staff and
dependents: One was located on the north side of Dhahran, across
the highway which separated the northern residential area from the
main corporate headquarters and its adjacent residential compound.
The other was built on the south side to serve the needs of the
larger community of foreign expatriates and their families. The
northern facility served the Saudis.
Hicke: The north side was the...?
51
Gelpi: The Saudi camp. And the south side was the so-called senior staff
camp. Both were connected by a tunnel, under the highway
mentioned by Bill Owen. And of course medical staff and patients
could move back and forth through this tunnel. The frame building
on the senior staff side was eventually replaced by a much larger,
two-storied structure, which became the Dhahran Health Center
(DHC), intended for hospitalization of all staff and their
dependents. Ultimately, the remaining frame building on the other
side of the highway became a clinic for Saudi dependent women and
children.
Hicke: I see. The south wooden building was abandoned with the building
of the new hospital. So the new one was for employees?
Gelpi: The clinic facility incorporated into the health center served
~ Saudi males and foreign expatriates with their dependents. The
two clinics--A and B--incorporated into the DHC hospital/clinic
complex served Saudis and foreign expatriates respectively. The
old frame building on the north side became clinic C. I saw
patients in all three clinics.
52
III FACILITIES AND PATIENTS
Contract Facilities
Gelpi: When I arrived in Dhahran, all inpatients, with the exception of
those briefly confined in district infirmaries, were hospitalized
at DHC . Later on we developed what were called "contract
facilities" in Al Khobar--the closest Saudi community to Dhahran.
These facilities consisted of small hospitals and clinics managed
by independent contractors who were selected by Aramco to manage
an overflowing population of Saudis and their dependents requiring
primarily inpatient care. A liaison team was established by
Aramco to monitor the designated facilities in Al Khobar in order
to maintain health care standards comparable to those within the
Aramco compounds: Dhahran, Ras Tanura, and Abqaiq. Referrals from
these district facilities could often be re-routed to the contract
hospitals in Al Khobar, when formerly, all would have been
destined for hospitalization in Dhahran.
Hicke: Who ran the contract hospitals?
Gelpi: These were usually managed by physician/entrepreneurs--Egyptian or
Lebanesewho set up the facilities with Saudi partners, then
extended their services beyond the community in which they were
located to Aramco employees and dependents.
Hicke: How about the nearby U.S. Air Force base at the Dhahran airport?
Gelpi: This base was clearly separated both geographically and
functionally from Aramco, as was the nearby consulate. I believe
that the consular staff and their dependents received care from
doctors attached to the U.S. Air Force military mission
headquarters at the Dhahran airport. This mission was assigned as
an advisory group to the Saudis, and interaction between its
medical staff and Aramco "s was perhaps more social than
53
professional. Later on, I got the air force people involved in
one of my research projects, however.
Hicke: Did you inspect these contract facilities? How did that work?
Gelpi: Eventually I participated in Aramco s liaison operation,
monitoring quality of care at the contract hospitals and clinics.
But then I was essentially responsible for evaluating the quality
of general medical servicesnot surgical, OB, or pediatric.
Hicke: What did that involve?
Gelpi: It meant making weekly trips to Al Khobar to evaluate patient
care, to discuss patient management at times, on an individual
basis and to attempt to reconcile standards and objectives of the
contract facilities with those of Aramco s health care program.
Hicke: Did they contract with the Saudi government also?
Gelpi: No.
Hicke: It was only with Aramco?
Gelpi: Right. The Saudi government provided overlapping health care
services with their own "government" hospitals and clinics.
Hicke: So the contractors came specifically to set up...
Gelpi: Yes, but certainly under the auspices of the Saudi government and
with Saudi opposites as partners.
Hicke: You were assigned to the contract facilities?
Gelpi: This was strictly an arrangement between Aramco and the contract
facilities. I was merely an Aramco delegate.
Hicke: So you sent them all their patients, either Saudi or American
Aramco employees?
Gelpi: Not at all. As I mentioned earlier, they also served the
communities in which they were situated. And certainly in the
evolution of the contract facilities, people with no Aramco
affiliation were encouraged to patronize these facilities. There
had been a time when Aramco found itself in the difficult position
of providing health care usually under desperate circumstances
to anyone in need, regardless of his or her affiliation with
Aramco.
Serving the needs of the general public, particularly if
representatives of this "general public" were even distantly
related to the royal family, were influential local merchants or
were government functionaries, at times required delicate
negotiations between Aramco s Government Relations personnel,
prospective patients, and members of Aramco s medical staff. In
effect, Aramco s doctors were sometimes being pressured into
admitting people with no Aramco affiliation who might just as well
have received care in one of the government s own facilities or
one of our contract facilities as a non-Aramco patient.
Hicke: Was Jim Knight the head of Government Relations when you were
there?
Gelpi: Yes.
Hicke: So you had to work out...
Gelpi: These negotiations often involved a prospective patient who might
also have status in the local or central Saudi government- -usually
someone with an uncomplicated medical or surgical problem. It
would involve a representative from Government Relations. And it
would involve an Aramco doctor, who was being asked to make a
decision about health care on the basis of the patient s
preference balanced against the patient s need. In final
analysis, the doctor had to decide whether the patient should be
admitted to DHC or sent to one of the facilities in Al Khobar.
Hicke: Were there Saudi facilities available?
Gelpi: The only government hospitals and clinics were in the communities
of Hofuf and Dammam, which were relatively primitive, when I
arrived in Saudi Arabia.
Trips to Qatar in 1960 and 1968
Hicke: Now I d like to jump ahead to the trip to Qatar.
Gelpi: Within a few months following my arrival in Dhahran, the ruler of
Qatar requested medical assistance from Aramco, presumably through
the Saudi government, and indirectly through Aramco s Government
Relations. Specifically, he requested that an Aramco doctor be
sent to Doha, the capital, and then to his large villa nearby. I
was sent with an Arab interpreter, who also represented our
Government Relations. Upon our arrival we were greeted by the son
of a most influential merchant in Eastern Saudi Arabia, Abdullah
55
Darwish, who spirited us off in his car to the emir s villa. As I
remember, this villa looked like a desert fortress right out of a
B-grade forties movie about the French Foreign Legion. We
actually went through an archway flanked by armed guards in order
to get to the inside courtyard. The emir s medical problem turned
out to be fairly severe, insulin-dependent diabetes.
His condition was being managed at the time by a British
physician, who may have been on loan from the local oil company or
permanently attached to the emir and his family. In any case,
this doctor was not happy about my arrival, thinking that he had
become superfluous. But he managed, with the usual understated
British aplomb, to be civil under the circumstances, if not
cordial. After interviewing the patient through my interpreter,
examining him, and talking with the British doctor, I made a few
suggestions, which included this doctor as an essential element in
the treatment plan. And everybody seemed to be satisfied. By the
time I left, my British colleague and I had established a "first
name" relationship.
This was not my last trip to Qatar. I returned in 1968 with
an Aramco team to investigate an epidemic of mass poisoning.
Hicke: Let s talk about that trip.
Gelpi: As I recall, it was just another day during the autumn of 1968.
Aramco was notified about a sudden, mysterious epidemic in Doha,
which had resulted in a number of deaths and a torrent of
seriously ill patients flooding the city s clinics and hospitals
in a matter of hours. This was on the heels of the Arab-Israeli
war of 1967, and there was still a great deal of tension between
the Israelis and Arabs. These tensions extended to the countries
bordering the Persian Gulf, including Qatar. In Doha, rumors
floated about possible Israeli biological warfare or chemical
contamination of Doha s water supply. There was no end to
speculation by the time the Aramco representation arrived on the
scene.
On arrival, we were rushed to the central hospital, where in
the waiting areas there were scores of people being triaged for
admissionsome unconscious, some convulsing, some vomiting, many
seriously ill, people at various stages of illness from this
mysterious poisoning or infection. Ultimately our team was able
to establish that this illness was due to mass poisoning from
dieldrin, an insecticide which had been shipped as cargo in a
compartment adjacent to a large shipment of flour. Apparently,
the dieldrin had somehow been mixed with the flour during shipment
or distribution. In any case, the supply of contaminated flour
was sent to a specific bakery; and all of those who became ill had
56
purchased bread or flour to make bread from this bakery on the
same morning.
Hicke: They used dieldrin for mosquito abatement?
Gelpi: Yes. But we didn t know what the poison was until much later,
after the initial detective work linking the illness to bread,
flour, a single bakery, and ultimately to the revelation that the
dieldrin and flour had been packed side-by-side in the shipment.
There was a point in the investigation when I found myself in the
morgue of the central hospital with its administrator and chief of
medical staff; I was insisting that we autopsy some of the poison
victims in order to analyze stomach contents. By that time it was
clear that we were dealing not with some exotic infectionnone of
the patients were febrilebut with some sort of poisoning. With
^the help of the World Health Organization and its laboratories, we
were ultimately able to establish the nature of the poison. But
the first steps included sampling stomach contents of some of the
victims who were fatally poisoned.
Hicke: That s how you found out what it was?
Gelpi: Partly. The real detective work was done by team members from
Aramco s Preventive Medicine Division. Here we had an epidemic,
and my Preventive Medicine colleagues started looking for
something in common shared by all the victims. What they had in
common was: they had all eaten bread or used flour to bake their
own bread, which they ate on the morning of illness or the evening
before. The flour had come from one bakery, and its most recent
supply of flour had come from one shipment; and so the links of
the epidemiological chain came together.
Hicke: So you just treated the symptoms?
Gelpi: Since the illness was self-limited, the survivors recovered with
simple supportive treatment.
Hicke: Was the bakery still producing bread when you got there?
Gelpi: I assume that it was. I don t know if it was ever shut down, but
it was certainly incriminated as the outlet for contaminated flour
and bread. This was not the first nor the last of epidemics of
this kind. There have been additional epidemics of poisoning
caused by foodstuffs contaminated with dieldrin and other
insecticides.
57
Health Care at DHC and Other Aramco Facilities; Patients
Hicke: Can you tell me something about the patients you were treating?
Gelpi: I was expected to provide personal care primarily for American
patients. They were managed very much like they would be in a
typical U.S. group practice. Those of us on the Internal Medicine
service provided both personal and consultative services for these
people. Some patients insisted on an American physician for
primary care, and others were referred by other doctors general
practitioners or surgeons. Some were referred from the districts
--Ras Tanura or Abqaiq. The referrals were both Saudis and non-
Saudi expatriates and their dependents. Most of us internists had
a fairly large proportion of Americans as long-term, primary care
patients .
As the years went by, I tried to get away from my role as a
primary care physician for Americans and more into the role of
consultant, teacher, and researcher. In this regard, I was quite
happy to spend more time managing Saudi patients and consulting on
the more complicated medical problems, both among Americans and
Saudis. I was particularly interested in some of the endemic
communicable diseases found in Saudi Arabia s Eastern Province.
But that s another story.
Hicke: We ll get back to that later. What kinds of problems were you
seeing in American patients anything unusual?
Gelpi: The usual: overweight, high blood pressure, ulcers, coronary
disease, the flu. But by and large this was a pretty healthy
population. There were the expected, common surgical problems:
appendicitis, hernia, gallstones, fractures, and other sorts of
trauma. We were dealing primarily with a younger population of
adults, not the typical mix of younger and geriatric patients you
would expect to find in the U.S.
Hicke: How about depression due to living abroad?
Gelpi: I think that there were probably a lot of psychological problems
of which we were only dimly aware. Later, when Aramco expanded
its medical services to include psychiatrists and clinical
psychologists, these problems emerged simply because they were
easier to recognize and easier to treat with the help of skilled
professionals.
58
Community Life
Hicke: Where were you living?
Gelpi: We were living in Dhahran. Our first house was a small duplex.
We soon became friends with our next-door neighbors. Within about
six months we were offered a larger home, right across the street
from one of Aramco s guest f acilities--Steinecke Hall.
Hicke: Oh, yes. It must have been named for Max Steinecke.
Gelpi: Yes. We remained there for the balance of our time in Dhahran.
Hicke: Was it comfortable?
j
Gelpi: I thought so. I thought all of the facilities were satisfactory.
Ultimately, we got our own furniturereplacing temporary
furniture on loan from the companyconsisting mostly of new items
purchased during our annual leaves, either in Europe or the U.S.A.
Aramco Medicine
Hicke: Tell me how Aramco s Medical Department evolved.
Gelpi: Its evolution during my stay included Dr. McCoy s transfer to head
the Abqaiq facility, as I have mentioned. This was probably about
the time that Dr. Page lefteither for retirement, for assignment
in the New York office, or possibly to take on a position with
another organization. I m not really sure. But upon his
departure, Dr. Daggy took over as medical director for all of
Aramco s health care services in Saudi Arabia. And shortly after
his transfer from head of Preventive Medicine to the position of
medical director, a new division of health care was created within
Aramco s Medical Department- -the Medical Services Unit. This
included Internal Medicine, Dhahran s General Practice group, and
Pediatrics. In all, this represented about twenty doctors. I was
asked to provide administrative and clinical supervision of this
unit. I didn t welcome the administrative responsibility, but
enjoyed the prospects of clinical supervision with its load of
teaching and consultation. Aramco s medical management was trying
to consolidate the various fragments of health care into larger
administrative pieces, for a variety of reasons.
Hicke: Why did those other departments come under Internal Medicine?
59
Gelpi: Well, the combination of General Practice, Pediatrics, and
Internal Medicine, Surgical, and Laboratory Services was to become
the Division of Clinical Services for purposes of administrative
convenience. The Medical Services Unit was the largest block of
physicians under the clinical and administrative leadership of one
person. And it just happened that this one physician was an
internist. So I had the largest group of doctors; and it turned
out that I was able to do then what many people in group practice
and academic medicine today would envy: About 25 percent of my
time was devoted to administration, another 25 percent to direct
patient care, another 25 percent to consultation and teaching, and
finally, another 25 percent to research. This is what many
department chairs in medical schools would love to do and can
rarely achieve because of overriding administrative
responsibilities. My teaching role evolved slowly, but gradually
became of increasing importance.
Hicke : Whom were you teaching?
Gelpi: I decided that the DHC was too isolated from the districts--Ras
Tanura and Abqaiq. Therefore, I planned weekly visits,
alternating with each district, to see problem patients and to
build noon medical conferences around case presentations. One of
the district doctors would present a case to the assembled group;
I would play the guessing game about the diagnosis typical of
teaching hospital conferences in the States and conclude with an
extemporaneous review of what was then known about the disease in
question. The idea was to keep the doctors up to date on changing
concepts of medicine.
I also started a medical journal club, primarily for those
interested in internal medicine, but certainly open to those of
our doctors in general practice. Anyone wanting to attend could
come. This was an after-hours affair, usually at one of our
internist s homes in Dhahran, after dinner, sometimes accompanied
by refreshments. We would review journals from our library, going
over various topics discussed in these journals, in an effort to
educate the assembled group about new concepts and discoveries.
Early on, we structured these meetings around a single topic,
rather than reporting on multiple topics from several journals.
As an example, the topic for a forthcoming meeting might be
coronary artery disease, and one of our doctors would review all
the available material on this subject over a period of several
years from the journals available in the DHC medical library and
from those to which he might have a personal subscription. To the
best of my knowledge, the journal club is still going.
Hicke: Oh that s good. It seems like a very useful idea.
60
Gelpi: After the 67 Arab-Israeli war, the district visits were
interrupted for a while, possibly because of local tensions among
our medical staff generated by the war and its aftermath. But for
eight years of my stay in Dhahran, every weekwithout fail--I
would be on the road for a round trip between Dhahran and one or
the other district medical centers. Some of the problem patients
whom I saw on these visits were hospitalized in the infirmary
attached to the clinic, and it was often from these patients that
one was selected for the case presentation. This allowed us the
opportunity of going to the bedside, examining a patient briefly,
and then returning to the conference room to discuss physical
findings and the progress of the patient while confined in the
infirmary. Later in the day, 1 would see referrals on an
outpatient basis in the clinic, leaving before the dinner hour to
return to Dhahran.
^
I believe that this was a rather successful activity: It
promoted a more collegial relationship between the doctors in the
district and those at DHC, it eliminated some of the costly and
time-consuming trips for patients between the districts and
Dhahran for consultations with the internists at DHC, and it
fulfilled a teaching function for which it was intended. And of
course, I enjoyed the experience.
Hicke: How many hours a day did you work?
Gelpi: This is difficult to answer. We had an on-call system, so that
one of us was on twenty-four-hour call every third day. Later on
this would include the physician assigned to the tuberculosis
service. So a typical day might begin at seven in the morning and
last until five or six in the evening, depending on the burden of
inpatients assigned to each of us, and how many clinic patients
were to be seen. I had my extra administrative chores, impromptu
visits to my office by colleagues, a stack of electrocardiograms
to be read from DHC and the districts each morning, an occasional
urgent visit to our emergency room to see a patient for possible
admission, the responsibility of seeing maybe one or two patients
after-hours--sometimes in the middle of the nightduring my on-
call rotation, and finally, Wednesday afternoon grand rounds.
Every week, about three p.m. on Wednesdays, we internists
would assemble with those general practitioners assigned to the
wards and from our general clinics who could be spared for the
occasion; and as a group, we would visit all of the interesting or
complicated patients on the medical service. The doctor managing
each case would make a succinct case presentation at the bedside,
and one or more of our internists would make some suggestions for
management or further diagnostic testing. I believe that these
61
rounds served the patients well and provided an important learning
experience for the doctors.
Finally, in answer to your question, I believe that 1 was
working fifty- or sixty-hour weeks, despite which I managed to
have lunch at home almost every day, and seldom had my dinners
interrupted by emergencies. My living just a few blocks from DHC
made response for emergencies quick and easy. On free weekends,
my family and I were often at the beach, the community pool, or at
the tennis courts. In many ways I was closer to my family and to
community activities than my colleagues in the States.
Hicke: Let s review this: There were departments for surgical,
preventive, and medical services.
Gelpi: The Medical Services Unit included Pediatrics, Internal Medicine,
and General Practice. The Surgical Services Unit included
Surgery, Anesthesia, and possibly Diagnostic x-ray. The
laboratory services were included in a separate unit; we got our
first pathologist soon after I arrived. There was Preventive
Medicine as a separate entity, a division. And of course, there
was the Nursing Service as an independent group. Here it may be
important to point out that we are talking about subdivisions of
the Medical Department, not about separate departments of surgery,
medicine, and so on. The arbitrary namesdivisions, and units-
had administrative significance, which was not always clear.
Hicke: When did you take over as chief of the Medical Services?
Gelpi: Either late 1959 or early 1960.
Hicke: Whom did you report to?
Gelpi: I reported to Dr. Daggy, our medical director.
Hicke: Whom would he be reporting to?
Gelpi: He would report to one of a rotating group of junior vice-
presidents assigned from a large pool of management people in
Aramco s Department of Industrial Relations (IR). This department
was responsible for most of the corporate activities not directly
related to oil exploration and oil production; and it might seem
that as a natural consequence, the Medical Department would be
administratively tied to IR. In theory, this seemed to make
senseparticularly to engineers and businessmenbut in practice
it did not work well. It didn t work well because representatives
assigned to the Medical Department from IR had their eyes on a
bigger prize, which was top-of-the-company management. It didn t
work well because their individual rotations in the Medical
62
Department s "proving ground" were too brief for the medical
director to get to know them, and for them to get to know the
details and changing requirements of our organization. In any
case, these IR guys were involved on a day-to-day basis with the
medical director in making policy decisions which affected the
health and welfare of so many people, including Saudis and foreign
expatriates, people living in adjacent, non-Aramco communities--
the whole Eastern Province of Saudi Arabia.
Hicke: Do you recall any of the names of people in Industrial Relations?
Gelpi: The one I remember the best was a Mr. Deveney or Deveny. He and
his family became our personal friends. As my first close contact
with Industrial Relations people, I believe that he was the best
pf a long line of IR representatives who worked with Medical
Department management. Unfortunately, he was killed in a
commercial airline crash along with other Aramco people, either in
late 1960 or early 1961. There were many others, best known to
Dr. [Julius] Bill Taylor, who had more direct contact with them
than I.
Aramco Provides Medical Services to the Royal Family
Hicke: As we move along, if you think about anecdotes concerning these
local celebrities, let s include them. You told me about the trip
to Qatar. Were there others?
Gelpi: I believe it was in 1961 that I was summoned to Riyadh to see the
minister of agriculture--Khalid Sudairi, I believe. The Sudairi
family was closely tied to the Saud family by marriage. This
middle-aged man suddenly developed severe gastrointestinal
bleeding, thought to be due to esophageal varices (varicose veins
in the lower esophagus). The varices develop in the lower
esophagus and in the lining of the upper part of the stomach in
people who have chronic liver disease. Because of increased back
pressure through the portal vein which drains the liver, one or
more of these varices may rupture, resulting in catastrophic
bleeding. Which is what occurred in this patient, on this
occasion. I gather that a member of the royal family close to the
King had requested medical assistance through Aramco s Government
Relations .
When I arrived at his bedside in Riyadh, this patient was not
doing well. His doctors had placed a tube--Sensteken-Blakemore
tubewith balloons at one end, which could be inflated both in
the stomach and esophagus to control bleeding. But it was in the
63
wrong place. Both balloons were in the stomach; and they were not
controlling the bleeding but were distending his stomach. This
was the right equipment being used in the wrong way. By deflating
the balloons, withdrawing the tube to the proper location,
reinflating the balloons, and exerting traction on the upper end
of the tube, the bleeding was stopped. We were able to obtain on-
the-spot blood donations, and we had brought supplies for cross-
matching blood and transfusions with us from Dhahran. Thus we
were able to transfuse the patient in his bedroom- -which happened
to be in a guest villa, because he refused to be moved to a nearby
hospital. Our patient made an uneventful recovery, later went to
Boston for surgery to correct his portal hypertension in order to
prevent further bleeding, and went on to live out a normal life
span.
Before I returned to Dhahran, I was asked by a representative
from the King to attend other members of the royal family. I
believe I was asked to see one or more of his wives, and as I
recall, their problems were medically insignificant. I suspect
that they were bored and were looking for a little excitement by
an unexpected visit from an American physicianfor a change.
Hicke: What were your problems in examining them?
Gelpi: These patients insisted on remaining in bed for their
examinations, which considering the size of the beds made contact
between examiner and examinee awkward. All of this was observed
by ladies-in-waiting, who were in attendance.
Hicke: Were these English-speaking, or had they an interpreter?
Gelpi: I m certain that I had an interpreter on location, either from our
Government Relations or from the royal family.
Hicke: What was Riyadh like?
Gelpi: In those days the capital was a relatively primitive, small town.
Besides the royal palace within the royal compound, there was not
much around except for the older, mud-brick structures so typical
of towns and villages in the Middle East. It wasn t until a
decade later that Riyadh began to be transformed into what it is
todaya modern city, by all standards. Of course it had its old
mosques, which presumably are still standing, and a market, which
no doubt, has been vastly expanded.
Hicke: Was there a hospital there, or a clinic?
Gelpi: There was a government hospitalprimitive, like those in Hofuf
and in Dammam (another town in the Eastern Province, near
Dhahran) . I believe that there was also a private hospital,
primarily reservedwith its stafffor members of the royal
family. But it was not unusual for those who could afford it to
seek medical care abroad.
Hicke: I know that during the early years Aramco people were sent to
Bahrain for treatment. Were they still doing that?
Gelpi: Not when I arrived. Bahrain has government medical f acilities--at
the time, they were somewhat more sophisticated than government
facilities in Saudi Arabiaand also had then a small clinic and
hospital operated by the Bahrain Petroleum Company. It is only
fifteen minutes away from Dhahran by airplane.
The Persian Gulf Medical Society and Aramco s Medical Department
Gelpi: Not too long after I arrived in Dhahran, I became involved with an
organization then known as the Persian Gulf Medical Society-
later, for various reasons, to be called the Arabian Gulf Medical
Society. Its membership consisted of a heterogeneous group of
physicians, mostly representing the medical staffs of various oil
companies and missionary medical centers scattered along the
coast. So we had members from Saudi Arabia, the emirates on the
Gulf s southern coast, Qatar, Kuwait, Bahrain, and Iran.
Strangely, Iraq was not represented; perhaps because of its newly
installed totalitarian government with its aversion to things
Western.
Hicke: What was the purpose of the society?
Gelpi: To bring various physicians working under similar conditions
together in a common cause: What experiences could we share in
respect to the medical problems we were seeing? What were the
effects of environment and culture on these medical problems? I
believe that the underlying purpose of this society was very
worthwhile, and I believe that my participation in the society
added a lot to my enjoyment of life in Saudi Arabia.
Hicke: This was for an exchange of information?
Gelpi: - An exchange of information; and it later turned out to be a forum
for developing research projects related to patient care and the
diseases encountered in the Persian Gulf area. This forum was not
remarkable in terms of scope and financial support. But doctors
were beginning to look at local medical problems with an
inquisitive eye, to start recording medical data, and to organize
65
this data for presentation at the annual meetings of the society.
So their observations were reported formally at our meetings, and
these presentations provoked discussions among the membership and
its guests.
Within perhaps one or two years after my arrival in Dhahran, I
was elected president of the Persian Gulf Medical Society. It was
just about the same time that we had the society meeting in
Dhahran. I was chairman for this meeting, and Lucille and I were
totally involved in all of the social arrangements. The meeting
was a great success, not only because of the quality of the
presentations and the social events which followed them, but also
because of the presence of a couple of guest speakers from the
faculty of the American University of Beirut s medical school. At
the time, one of the guests--Dr. John Wilson--was chairman of the
department of surgery at the university. He later went on to
become the dean of Stanford s medical school; and we have been
close friends ever since.
Hicke : Let s continue with more about this medical society.
Gelpi: From then on, we had annual meetings in various placesBahrain,
Kuwait, and Abadan, Iran. Perhaps the real moving force behind
these meetings, at least while I was with Aramco, was the Persian
representation from the National Iranian Oil Company (NIOC).
Hicke: Who represented NIOC?
Gelpi: A Dr. Massoud Rouhani. Eventually, the Iranians began to think of
this as their own society, even though I was president of this
society. There are even thoseand I think that they would be
Saudis, Kuwaitis, Bahrainis, and others- -who would suggest that
the society had become an instrument of NIOC and Iran. Of course
this wasn t all bad, as far as I was concerned, because the NIOC
and its doctors were generous hosts, when the meetings were held
on Iranian soil. But inevitably, there was a problem.
The problem centered around the name of the society, not so
much its Iranian membership. The Gulf Arabs insisted that the
Persian Gulf was misnamed, that it should be called the Arabian
Gulfthis, despite the fact that in almost any world atlas it is
called the Persian Gulf. The sides were drawn, and I was
inadvertently on the wrong side: as president of the society and
an Aramco employee I tacitly represented the Arabs or so the
Iranians believed. And it was about this time that I was to turn
over the presidency to Dr. Rouhani. Soon I found myself in the
midst of an international controversy- -words had been exchanged
between the governments of Saudi Arabia and Iran about all this.
The Saudis insisted the name of the society be changed; the
66
Hicke:
Gelpi:
Iranians wanted the name to remain. I wanted to compromise, and
what I had in mind was two medical societies the Persian Gulf and
maybe the Arabian Medical Society. They could have joint
meetings.
So it was that on the veranda, overlooking the marina, next to
the St. George Hotel in Beirut, NIOC s Dr. Rouhani and I met to
work out the compromise. By that time our friendship had become
somewhat frayed, and I believe that both of us were looking for an
easy way out. What we decided was to have the two societies one,
the Gulf Medical Society, the other, still the Persian Gulf
Medical Society.
And did that work out?
It relieved tensions. And when I left Saudi Arabia they had
started to have meetings of the (Arabian) Gulf Medical Society.
Whether or not they included an Iranian representative, I don t
know.
67
IV HEALTH AND DISEASE IN SAUDI ARABIA
[Interview 2: January 3, 1996]
Smallpox
Hicke: Let s start this afternoon with smallpox. Can you tell me
something about the problems there, and what you were doing to
solve them?
Gelpi: When I arrived in Dhahran, I was aware that smallpox was endemic
in the Eastern Province. I was told that the governor of the
Eastern Province had launched a vaccination program to include all
of the Saudi residents under his jurisdictionwhich would also
include Aramco s Saudi workforce. How successful the vaccination
campaign would be was uncertain at the time; but within a few
years it was clear that smallpox had been eradicated in the
Eastern Province.
Hicke: Was there resistance among the Saudis to vaccinations?
Gelpi: Since this was essentially a government program, Aramco was only
secondarily involved, and, to answer your question, I m not aware
that its Saudi employees were resistant to vaccination. But
Aramco was also involved to the extent that some of its employees
and their dependents contracted the disease and were hospitalized
in Aramco facilities. I can recall that during my first year with
Aramco there were always two or three cases of smallpox confined
in isolation beds on our medical service at DEC. I have excellent
color slides of a number of these patients dating back to that
period. Within a couple of years smallpox had vanished from our
medical facilities, and, I presume, from nearby communities in the
Eastern Province. What the situation was in the rest of the
Kingdom is uncertain, because there were no reliable epidemiology
reports from any source reflecting patterns of communicable
disease in Saudi Arabia at the time.
68
Hicke: I read that they were doing surveys of the villages. Was that in
regard to smallpox?
Gelpi: No. The major surveys conducted by Aramco were related to malaria
control and the epidemiology of trachoma. Aramco was not looking
for smallpox in the Saudi villages. We saw smallpox when its
victims came to the hospital, and these were mostly Saudi
employees and their dependents.
Malaria
Hicke: Now, malaria is quite a long story; and I know you want to talk
about Richard Daggy s part in that.
Gelpi: Yes, why don t we talk about malaria. Perhaps the first major
disease that appeared with any frequency among the Saudis employed
by Aramco was malaria. This was apparent from the number of
Saudis hospitalized for this disease, and it prompted an
investigation of malaria, initiated by our Division of Preventive
Medicine. The prime mover here was Dr. Daggy, as head of
Preventive Medicine.
Hicke: What time period are we talking about here?
Gelpi: This would be the mid to late fifties. Daggy initiated annual
village surveys, which included most but not all of the villages
of the Qatif oasis north of Dhahran and the Al Hasa oasis, which
is about forty or fifty miles south of Abqaiq. These annual
surveys were carried out continuously during my employment with
Aramco.
A team from Preventive Medicine would go to each village and
take blood samples from a cross-section of its residents, which
included a high proportion of infants and children. The team
would survey about a dozen villages on an annual basis, and on the
basis of microscopic examination of each blood sample, determine
the types of malarial organisms infecting the population, perhaps
the duration and intensity of infectionbased on feeling enlarged
spleens in people examinedand also the proportion of people
infected.
There are four species of malaria which infect humans, three
of which were carried by mosquitoes in the Eastern Province. The
organism causing the most dangerous form of the disease,
Plasmodium falciparum, was present in the Eastern Province and
accounted for a high proportion of infections. Any one of the
69
four types may cause severe illness, but falciparum is clearly the
most dangerous because of the intensity of infectionthat is, the
large number of organisms often present in human infections.
Hicke: Well, I m going to ask you some questions, the answers to which
may seem obvious to you but might not to me or some reader.
Malaria comes from mosquitoes; so I suppose the malaria developed
in the oasis areas primarily. Well, would the oases be the normal
areas of civilization anyway?
Gelpi: The oases were heavily populated, and had been, as far as we know,
for millenia. And the reason for this is that there were natural
water sources which encouraged the development of agriculture.
Typical oasis agriculture centered around cultivation of the date
palm, but the soil and irrigation systems in these oases supported
cultivation of a variety of vegetables.
The water sources, while not necessarily stagnant, supported
the development of mosquitoes; and of course mosquito control
became a central element in malaria control. Mosquito abatement
was accomplished by means of a three-pronged attack: residual
spraying with insecticides, starting with DDT; spraying oil on
stagnant bodies of water to discourage the development of mosquito
larvae; and the introduction of larva-eating (larvacidal) fish,
minnow- like gambusia. There were some attempts at hydraulic
engineering to control flooding, irrigation sources, and to divert
irrigation away from densely populated areas.
Our main malaria carrier (vector) was, and is, a bug called
Anopheles stephensi. Fortunately this mosquito has a short flight
range, so that communities outside of the oases were less likely
to be affected by malaria. The control measures introduced by
Aramco were quite effective in largely eliminating A. stephensi
from the oases and surrounding areas.
Hicke: This sounds like it s part of a whole land-use issue--dif ferent
patterns of irrigation.
Gelpi: Maybe the key control measure was residual spraying. The oil
spraying and the use of larvicidal fish were perhaps of secondary
importance. Residential residual spraying was probably crucial.
Hicke: Was the spraying done by the government, the Saudi government?
Gelpi: It was a cooperative enterprise, which at least at first involved
Aramco. But Aramco was always intimately involved as an
interested bystander, because a large proportion of its workforce
came from the oases and town sites nearby. Later, there were
increasing numbers of employees from other parts of the Kingdom;
70
but initially, Aramco depended for much of its manpower on the
local Saudi population.
Hicke: Would the spraying programs have been developed by Aramco?
Gelpi: Yes, in consultation with an entomologist who was part of Aramco s
Preventive Medicine team.
Hicke: Do you have any idea about who started the residual spraying and
when?
Gelpi: I can t give the details. Either Dr. Richard Handschin or Dr.
Daggy would be the most reliable sources for this information.
And we do have some published material which may deal with this
issue.
Hicke: Is there anything more you can tell me about Dr. Daggy s work?
Gelpi: In 1959 he published a rather large monograph on malaria in the
Eastern Province, which was included as a supplement to its
monthly journal by the American Society of Tropical Medicine and
Hygiene. 1 I ll be including this in a bibliography to accompany
these oral histories. In effect, this publication describes the
conditions prevailing in the oases which led to endemic malaria,
the effects of malaria on the local populations, the control
measures applied, and the results of control measures in terms of
the declining frequency of infection among oasis inhabitants. The
publication says something about coordinated efforts between
Aramco and the Saudi government to develop malaria control and
eradication in the Eastern Province. And it describes the results
of control measures against the backdrop of annual village
surveys .
Aramco s Health Care Program and the Saudi Government
Hicke: What was Aramco s relationship with the Ministry of Health?
Gelpi: There was a longstanding relationship on the basis of referrals
from government medical facilitiesusually for urgent medical
care--in areas where Aramco s hospital and clinics were close
enough to make such referrals practical. Aramco had an open
Richard H. Daggy, "Malaria in Oases of Eastern Saudi Arabia,"
American Journal of Tropical Medicine and Hygiene. Vol. 8, No. 2, Part 2
(March 1959), 223-291.
71
policy which permitted its doctors to make discretionary decisions
about need, and, as you might expect, about how interesting or
educational such referrals might be as patients in our hospital.
In a sense, government and Aramco health care practices frequently
converged, based on proximity, subtle pressures through our
Government Relations staff, and the type of illness being
considered.
Hicke: Was this a formalized policy, do you know?
Gelpi: As I have implied, I don t believe it was ever formalized; rather,
it was a tacit understanding which gradually evolved between local
government functionaries and Aramco--an arrangement modified from
time to time, depending upon local needs, changes in Aramco
management, and upon the potential overuse of Aramco medical
facilities by non-Aramco patients. When our hospital was full,
this led to our discouraging hospitalization at DHC of people with
no Aramco affiliations, particularly at a time when we began to
encourage admissions to our contract facilities in Al Khobar.
Hicke: This must have created reporting and record-keeping difficulties.
How did this work?
Gelpi: I m certain there were difficulties in keeping medical records.
It was easy enough, in each designated contract facility to keep
records of admissions, discharges, and diagnoses. And at any one
time we had a rough idea of the sorts of medical problems which
were being managed, and an even better idea about actual numbers
of people coming from and returning to Aramco medical facilities.
I don t believe that this was duplicated in government clinics or
hospitals; and if it was, we really had no access to such records.
Often, patients would be transferred to DHC from a government
facility with virtually no information except personal
identification, a sentence about the nature of the illness, and a
statement that the government doctors couldn t handle the problem.
Hicke: Yes, that s what I was thinking about. And there s the problem of
whom to call if the patient has a further problem or complaint.
Gelpi: If the patient was referred to Aramco, he was usually sent to us
indirectly through our Government Relations. This triage system
acted to screen out people who were far removed from any
connection with Aramco, who had a minor medical or surgical
problem, and who were not intimidating in terms of their high
connections. And Government Relations people had to use great
discretion when caught between reluctant medical staff and
persuasive patient advocates. Sometimes the pressures were
extreme, as in the case of a very influential person in
government. And the intensity of these pressures, opposing the
72
diplomacy of Government Relations, determined the ebb and flow of
non-Aramco patients into our health care system.
More about Aramco and Malaria Control
Hicke: What was the status of malaria in the Eastern Province when you
left?
Gelpi: In the period of eight years, while employed by Aramco, I saw a
progressive decrease in the incidence of malaria. And I don t
think there is any question that this was directly attributable to
Aramco s program of control and year-by-year monitoring initiated
by Dr. Daggy, which was eventually picked up by the ministry of
health. That is to say, Aramco s Preventive Medicine people
provided essential information about the intensity and
distribution of malaria in the oases. The government ultimately
provided incentives and means for malaria control. I think I may
have arrived at a time when malaria had reached its second apogee
(the first was actually in the forties). And I left Aramco at a
time when there were relatively few cases. So we re talking about
a span of maybe a decade in which there were profound changes in
the endemicity of malaria.
Hicke: Were Americans getting something to combat malaria? I don t know
when it was developed, but I know now you take pills if you go
into an area where there is danger of infection.
Gelpi: Americans lived relatively close to the malarious area. But as
far as I know, with the possible exception of some daring campers
or passing travelers, foreign expatriates simply didn t get
malaria living in Dhahran or the districts. This was mainly
because the mosquito vector has such a short flight radius. In
summary, foreigners, including Americans, did not have to take
prophylactic medication because they were protected by distance.
Hicke: Is there anything else about malaria that you d like to mention?
Gelpi: I got interested in the malaria surveys because the village survey
seemed like a good vehicle for doing other kinds of research. In
other words, if you were using blood sampling in the surveys, you
could be testing the samples for other things besides malaria.
And that s where I came into the picture later onsampling for
the sickle cell trait, and for a genetic marker called red cell
G6PD, which we ll get into. So I went piggyback on the annual
malaria surveys for a couple of years. It was a wonderful way to
collect hundreds of blood specimens, and to process them in my
73
laboratory with the kinds of tests that were available to me. In
a way, this testing was relevant to malaria, because the disease
is closely associated with both the sickle cell trait and G6PD
deficiency. More about this later.
Hicke: So actually, the village surveys established a certain precedence.
Gelpi: Yes. I think they probably introduced the villagers to the idea
that strange people entering the village for what seemed to be no
particular therapeutic role were nevertheless providing services,
indirectly; and actually, once they got the idea that somehow this
might lead to improvements in their lives to less diseasethey
seemed to be quite willing to cooperate.
Hicke: They didn t mind being "stabbed"?
Gelpi: No, this was done with such skill that it was relatively painless.
Most of the subjects were infants and children, and the sampling
did not involve puncturing a vein for blood, but just a finger
stick or an earlobe stick with a sharp lancet to obtain a few
drops of blood. There really wasn t any trouble getting the
villager to cooperate.
Trachoma and Aramco s Trachoma Research Project
Hicke: Next on my list is trachoma, and I know that was a big project.
Gelpi: Ideally, the people that could best discuss trachoma are those who
were the active participants in the research project. Of all
those involved, Dr. Jack Snyder, representing the Harvard School
of Public Health, was the prime mover, and he would be the right
person to talk to. But as a physician...
Hicke: And we don t know if we re going to get to talk to him. Whom
would he have worked with at Aramco?
Gelpi: Dr. Roger Nichols, who represented the Harvard program in the
field, with headquarters in Dhahran. Another was Dottie McComb, a
full-time technologist sent to Dhahran on a more or less
indefinite basis to work in the laboratory and in the field with
Dr. Nichols on village surveys. These surveys were not done in
conjunction with the malaria project, but independently, to work
out the distribution of trachoma: which villages were involved,
how many people were affected, and so on. The Harvard /Aramco
trachoma project lasted almost twenty years, from the mid-fifties
until the mid-seventies.
74
Hicke: I have it as beginning in 1954. Do you know how it got started?
Gelpi: When I arrived in Dhahran I was not aware of the origins of the
trachoma project; nevertheless, it was in full swing. The
laboratory was on the second floor of Dhahran Health Center, and
the people engaged in the project were involved in a vigorous
program of village surveys to isolate the organism which causes
trachoma, to grow the organism in eggs, and to refine a new
technique for staining the organisms in eye scrapings. This
technique consisted of tagging antibodies against the trachoma
organism with a fluorescent dye, then putting the antibodies on
eye scrapings to combine with the trachoma organism so that the
trachoma would shine as brilliantly fluorescent particles under
the microscope. This is a very powerful tool, and more specific
than the usual methods for staining cells and tissues for viewing
under the microscope. And of course this makes it useful in doing
surveys on large numbers of people who are suspected of being
infected with the trachoma organism.
Hicke: It sounds like there must have been a sophisticated lab.
Gelpi: It was. And the people who were operating the laboratory were
using techniques which they had imported from the United States
for doing epidemiological studies to track down eye infections,
and for being able to decide whether these infections were due to
the trachoma organism or some other cause.
Hicke: Was Dr. Snyder actually on site?
Gelpi: He may have made site visits, but basically he was at the Harvard
end of the operation. There were comings and goings of people
from the Harvard School of Public Health who were interested in
various aspects of trachoma and in other eye infections. There
was a need to review progress, to keep the operation funded, to
establish and develop research priorities, to enter the results
into peer-reviewed publications for various journals, to interact
with Aramco management on behalf of the trachoma program, and to
interact with personnel in Aramco s Medical Department.
Hicke: But they weren t doing any of the actual lab work?
Gelpi: They may have, but it would have been correlativechecking
resultsand at least some of this would have been done back at
Harvard.
Hicke: This went on for how long, do you know?
Gelpi: From 1954 probably to 1973 or 1974. I m not exactly sure when the
trachoma project was officially terminated.
75
Hicke: Did it have anything to do with your work at all?
Gelpi: I had little to do with the trachoma project. The existence of
trachoma and malaria research sponsored by Aramco persuaded me
that other types of medical research might be welcomed. It seemed
to me that there were other problems waiting for research
projects, and that encouraged me to start looking.
Q Fever in Saudi Arabia
Gelpi: I m trying to think of the first possible investigation that
interested me. I guess that the place to start would be
mentioning a disease which really hadn t been either diagnosed or
defined before my arrival. It had probably existed for quite a
while. Every year there would be a minor epidemic of an
influenza-like illness among Americans and other foreign
expatriates living in Aramco residential facilities. This was
passed off as a type of flu that you might see in the U.S. The
Aramco epidemic would occur about the same time each spring.
I happened to have a couple of the victims sick enough to be
admitted to our hospitalas patients. Each had a pneumonia; and
besides x-ray evidence of the pneumonia, they had abnormal liver
function tests. This would be quite unusual for otherwise
uncomplicated viral pneumonia, which sometimes occurs with the
flu, or influenza. And this got me to thinking about similar
illnesses I had encountered in the United States, when I was
working at the VA hospital in Fresno. In that case I remember
some patients with pneumonia and abnormal liver function tests who
turned out to have Q fever. I won t go into a lot of detail,
except to say that Q fever is a disease caused by a microorganism
called Coxiella burnetti, bigger than a virus, smaller than
bacteria. It basically causes infections in domestic animals-
sheep, goats, and cattlewhich may secondarily be transmitted to
humans, causing an inapparent infection, but sometimes causing
disease which may be very severe.
It turned out that my two Aramco patients had Q fever. We
didn t make the diagnosis by isolating the organism- -which is a
risky thing to try in the laboratory but by finding specific
antibody against Coxiella in blood samples from our patients. The
precision of this test lies in comparing the level of antibody
early infection with that during recovery. If the antibody level
jumps up, this is attributed to Q fever infection. So presto, you
have a diagnosis!
76
It seems that this disease was endemic in Saudi Arabia. To
make a long story short, I was able to demonstrate infection in
goats and sheep. And I was able to show that a new dairy herd
(cattle), which had been sent to Hofuf from Denmark, was free of
infection shortly after arrival. The same herd was found to be
infected when retested a year later.
Hicke: How did humans become infected?
Gelpi: Certainly Americans and other expatriates with Q fever were not
getting it from close contact with Saudi livestock. But during
parturition- -the birth of lambs, kids, and calves- -great amounts
of infectious material are released into the environment, and
under conditions of periodic high winds, which occur starting in
the spring and continuing into the autumn, organisms are
presumably dispersed great distances. And of course the birth of
these animals typically occurs in the spring months in Saudi
Arabia.
There were reports that Americans working for Aramco and for
the American consulate in Riyadh were experiencing the same "flu."
But, rather than look for antibodies against Coxiella in blood
samples from this group, I used a test in which non- infectious
material from this organism is injected under the skin. And it
was possible to show that quite a few had Q fever infection. The
skin test is similar to that used to detect tuberculosis. The
survey was conducted by Dr. Ivan Alio, epidemiologist for our
Preventive Medicine Division.
I was also able to show that high proportion of Saudis had had
previous infection, most likely inapparent; that one could expect
positive skin tests in Americans who had lived in Saudi Arabia for
more than brief periods; and that the longer one had resided in
Aramco residential areas, the more likely one was to have become
infected.
Finally, I was able to investigate a population of airmen
attached to the U.S. military mission at the Dhahran airport with
the help of medical officers who were part of the mission. These
people were assigned for two years of duty in Saudi Arabia; so it
was possible to test new arrivals, and compare them to those who
had been around for a while. And of course those who had been
assigned the longest were more likely to show positive skin tests.
They may not have remembered being ill; but indeed, they had been
infected. So it became obvious that seasonal Q fever was pretty
widespread in Saudi Arabia s Eastern Province.
Hicke: Can you elaborate a bit on how you actually organized the
research, such as filling out forms, requesting permission...
77
Gelpi: I had to ask permission from every person upon whom we took a
blood sample or did a skin test, which required that I explain the
purpose of testing. In the case where I extended the testing to
animalsobtaining samples of blood and/or milk, looking for tell
tale antibodies--! had to explain what was going on to the owners.
I remember on one occasion in the desert asking a Bedouin herdsman
for permission to test his goats and sheep. He was amused, but
quite ready to let me do the tests on his animals, and then
invited me into his tent for tea and an introduction to his
family.
Hicke: How about camels?
Gelpi: That is an interesting question. I was not able to test camels
for a variety of reasons. But I did just about everything else,
still suspecting that camels were involved. I found a way to test
milk samples for antibodies, and I was able to use this on cow s
milk. Taking blood samples from cows is not easy; but I obtained
blood and milk samples from cows and goats and found that they
have antibodies in the milk.
Hicke: Were you doing this testing yourself?
Gelpi: I did the sampling, testingexcept those skin tests that I
mentionedand all the laboratory work by myself. But I sent some
serums away for special testing at laboratories in the United
States, and a few to our serology lab, operated by Preventive
Medicine, at Dhahran Health Center for tests on clinic and
hospital patients suspected of having Q fever.
Hicke: What kind of support did you get from Government Relations?
Gelpi: I told Government Relations what I was doing, insofar as it
affected people not directly connected with Aramco; and I
certainly cleared the work with our medical director. Beyond
that, I carried out the negotiations and other arrangements
myself. In fact, I went to the dairy owner in Hofuf in order to
sample his cattle, telling him exactly what I was doing and
getting his permission. It actually seemed that I was welcomed.
I was questioned, which was appropriate, but I was never turned
down.
Hicke: Did you take an interpreter?
Gelpi: Oh yes, I took along an interpreter. My Saudi hosts were
generous, interested, and helpful, and I really didn t have any
obstacles. My only obstacle was limits on my time and personal
effort I was able to put into this type of research.
78
Hicke: Did you develop any preventive procedures?
Gelpi: The whole idea, of course, was to provide effective treatment and
prevention. But the idea of controlling itinerant herders and
their animals didn t turn out to be very practical. What was
practical, however, was to recognize that some of the illness
passed off as the flu could be successfully treated with certain
antibiotics specific for Coxiella infections. Having a high index
of suspicion in patients with the combination of pneumonia and
abnormal liver function tests that an illness was Q fever would be
enough for the attending physician to start treating with the
appropriate antibiotic to shorten its duration.
Hicke: Would the patient have to be hospitalized?
Gelpi: Probably the vast majority of people who got this infection were
no sicker than those who might have stayed home with a fever for a
couple of days, thinking that they had the familiar flu. They
wouldn t go to the hospital. Some would be quite ill. This
disease can be potentially deadly in those individuals with a
heart valve defect. The Q fever bug can attach to the damaged
heart valve and cause severe complications, which can be fatal.
Hicke: Was Q fever still occurring when you left?
Gelpi: I have the sinking feeling that once I had stopped research on Q
fever nobody else picked it up. As far as I ve been able to tell,
since I left in 1968, I have seen no other publications on Q fever
in Saudi Arabia after my own. Q fever has been recognized in
other Middle East countries, notably Israel and Iran, but I have
seen nothing about the infection in Saudi Arabia. Among the
people with whom I was working in Araraco, and also among the
Saudis although engaged in all sorts of other medical research-
there has been no evidence of recognition or interest.
Hicke: You went back there in the seventies, and you did not hear
anything about it?
Gelpi: No, but I have no reason to believe that there isn t just as much
Q fever now as there was then. As long as there are herds of
sheep and goats wandering around in the desert, and as long as
these herds are near settled areas, such as the Aramco communities
and other towns in the Eastern Province, there is every reason to
believe that people are still getting infected.
Hicke: There s nothing that will prevent the animals from...
Gelpi: From acquiring and transmitting infection? I m not sure, but for
veterinary purposes, there may be a vaccine for this. But there
79
is no vaccine for humans, as far as I know. During the Desert
Shield/Desert Storm engagement, this issue was brought to the
attention of our military people, who were concerned about the
possibility of the Iraqi use of biological warfare agents against
our forces. I don t think that Coxiella would be an effective
agent, even though small doses cause infection. However, I don t
think the enemy was seriously considering it, for there are much
more dangerous and effective agents for use in biological warfare,
Pulmonary Ascariasis
Hicke: What else were you working on?
Gelpi: Another pervasive, even more interesting medical problem was what
we call pulmonary ascariasis. There is a parasitic worm, Ascaris
lumbricoides , which together with the pinworm accounts for most of
the human worm infections in the world, particularly in third
world countries. In Saudi Arabia, every year during the spring
months, we would see quite a few cases of pneumonia among Saudis.
The strange thing about this type of pneumonia was that it seemed
to change day by day, depending upon how often one takes x-rays,
which is unusual. Secondly, it was associated with a marked
increase in a certain type of blood cell called the eosinophil.
These two findings, that is, a changing x-ray picture of the lungs
together with an increase in the number of eosinophils in the
blood, made a distinct syndrome.
Hicke: So this is a kind of pneumonia?
Gelpi: Yes. Mild fever, with the main symptom a severe cough. The
patients didn t seem very ill, but they all had a severe,
constant, uncontrollable, dry cough. Some coughed so much that
they were exhausted from lack of sleep, and perhaps this symptom
alone led to a hospital visit. Getting an x-ray with a rather
alarming, extensive pneumonia would lead the admitting physician
to think that the patient was a lot sicker than he or she actually
was, and this would prompt admission. Once in the hospital, these
patients would be treated with various types of antibiotics,
without a clear diagnosis or notion of what was going on.
It occurred to me, in seeing some of these patients as a
consultant, that this might be a parasitic worm infection because
of the very high levels of eosinophils in the blood of every
patient. What type of worm infection could be common out here?
This was rather easy to determine, because our Preventive Medicine
people and laboratory service had carried out surveys, using stool
80
samples for microscopic exams. Of course, ascaris infection was a
fairly frequent finding.
The next question was: why would ascaris cause pneumonia, and
how would it cause pneumonia? Because this is an intestinal
parasite. The answer is clear. The infection starts with
ingestion of eggs from the adult worm under conditions of poor
sanitation. The eggs mature into larvae (minute, motile worms).
The larvae penetrate the wall of the intestine and actually
migrate through the intestinal veins into the liver, and
ultimately the lung. Here they migrate through the small
capillaries into the alveoli--the little air sacks and then up
the bronchial tubes to the esophagus, where they are carried into
the stomach, finally lodging in the small intestine to reach
maturity. The male and female worms copulate, eggs are produced,
which pass through the intestine into the stool, and the cycle
begins once again.
Hicke: It sounds like that "Journey Through the Bloodstream" movie!
Gelpi: It s really quite an incredible journey. Actually, during the
migration of these second stage larvae, as they move through the
lungs and bronchial tubes, they create intense inflammation,
leading to the severe cough and the characteristic widespread x-
ray changes in the lungs. When you look at typical x-rays, you
see what is called a "patchy" pneumonia, which in some wayswith
just a single x-raymight be difficult to distinguish from viral
and bacterial pneumonias.
By the time the larvae have completed their journey from
intestine through the liver and into the lungs, they have
stimulated the body to produce protective antibodies. The body
becomes aware of the invader and produces antibodies; but nothing
much happens until the larvae reach the lungs. And there they are
held up. For by this time the antibodies are attracted to the
larvae, and these larvae are releasing proteins called antigens-
unique to A. lumbricoides which combine with specific antibody to
form complexes which cause the intense inflammatory reaction which
results in a pneumonia which skips around in the lung a migrating
pneumonia.
Hicke: Tell me how you found all this out.
Gelpi: The best answer is serendipity. I think it was Louis Pasteur who
suggested that every time you have an accidental discovery, if it
does not prompt some sort of critical thinking or reasoning, your
efforts have been wasted. We were able to identify the typical
larvae in the sputum of several patients, which allowed me to
prove my point that the pneumonia was an allergic reaction to the
81
worms. We were able to markedly relieve the symptoms by injection
of what we call adrenocorticosteroid hormones --which don t cure
infections, but which powerfully suppress inflammation. An
example would be the use of a drug called prednisone, which is
used to treat people with severe asthma, who often have increased
blood levels of eosinophils, and who resemble our patients with
ascaris pneumonia in certain ways. This worked well in treating
patients who were quite ill, because the condition is self-
limited. Once the larvae get out of the lung and into the
intestine, all the symptoms subside.
Hicke: So prednisone reduces the inflammation?
Gelpi: Yes, by reducing the effects of the antigen-antibody reaction
which I described. This reaction is somewhat similar to what
happens when someone with hay fever gets pollen on their nasal
mucus membranes and in their eyes. There are antibodies in the
membranes which recognize the pollen proteins, and complex with
these antigens to produce a local, intense reaction, which we call
allergy. This results in the familiar symptoms of sneezing and
itching, inflamed eyes. This is similar to what goes on in the
lungs and bronchial tubes of people with ascaris pneumonia.
Hicke: Over what period of time did you work on this?
Gelpi: I worked on it for a couple of years, and then got out a couple of
publications on the problem. 1 I had reason to hope that this might
prompt people to be more aware of this condition throughout the
Kingdom. Subsequently, I have seen no more publications on this
disease from Saudi Arabia or elsewhere in the Middle East. But
there is also reason to believe that with time, and the great
improvement in the level of sanitation and public health, the
disease is disappearing on its own, and that special intervention
isn t necessary. But I d also be willing to bet that there are
many countries in the world which share the seasonal conditions
which prevail in Saudi Arabia and which promote this type of
infection.
There are probably many, many people who have a type of
pneumonia similar to what was occurring with the Saudis. What
made this a seasonal condition in Saudi Arabia is that the ascaris
eggs will not survive in high temperaturethe temperatures which
prevail on the Arabian peninsula from late spring into late
autumn. It was only with the winter rains that conditions became
optimal for transmission of ascaris infection, so that we would
see most of our patients in the months of March through May.
See Bibliography.
82
Hicke: Has this been found in other parts of the world?
Gelpi: It has been described elsewhere. Perhaps the earliest publication
on this problem came from Switzerland, of all places. The report
indicated that human waste was being used for fertilizer to grow
produce, and that some of the farmers were becoming infected with
ascaris . But as a seasonal medical problem, the first
publicationsmaybe the lasthave been from Saudi Arabia.
Hicke: When did you publish this information?
Gelpi: It was published from the mid to late sixties, and represents
another step in our understanding of human parasitic infections
and in our understanding that some types of pneumonia are really
not what they seem, but that they re due to worm infection.
Hicke: At Dhahran Health Center, they re still aware of your work?
Gelpi: I doubt it. I ve learned that published research is soon
forgotten, unless there is some reason for resurrecting somebody
else s research and applying the results. If researchers don t
recognize that earlier work is relevant, they re not going to read
a paper that was published twenty years ago, just out of
curiosity.
Hicke: I can understand that.
Gelpi: I suspect that the problem of pulmonary ascariasis has gone away.
The reason I believe this is because conditions in residential
areas where many of our Saudi workforce and their families lived
during the fifties and sixties have markedly improved in terms of
sanitation. You re not seeing the soil contamination with human
waste which was apparent then.
Hicke: That s what produces the worm?
Gelpi: That s what allows the worm eggs to get into the food chain, to
recycle the infection. So better plumbing has helped with a lot
of things.
Cancer
Hicke: What else were you working on?
Gelpi: One of the problems which interested me out there was cancer in
Saudis. We were dealing then with a relatively young population,
83
in which you wouldn t expect to see certain cancers which were
relatively common in the United Statesprostate, breast, colon,
and lung cancer. We simply weren t seeing much of this in Saudis.
The fact that we were seeing mostly young adults and children in
our hospital and clinics made comparisons with representative
populations in Europe and the United States and Canada unreliable.
Hicke: The Saudi population was younger because the life span was
shorter?
Gelpi: Most of our employees and their dependents were young. So we were
looking at a special group of people in a special environment.
And it turned out, interestingly enough, and not unexpectedly,
that the type of cancers we were seeing were different. It was my
colleague, Dr. Bill Taylor, who published the first paper on
cancer in Saudis, which appeared in the journal Cancer, in the
late fifties or early sixties. 1
He was finding the kinds of cancers that you might expect to
see in a relatively confined, middle-class, younger population in
a Western count ry--leukemias and lymphomas--rather than in a
population with a broader age representation. And I noticed that
a number of patients I was seeing in the hospital had what we call
abdominal lymphoma. They presented with abdominal pain, or
abdominal swelling, or both. And it was usually not clear what we
were dealing with until some had exploratory surgery and were
found to have lymphoma involving their intestine, the lining of
the abdominal cavity, or in the abdominal lymph nodes. This
seemed to be quite a bit different than the usual presentation of
lymphoma in Western countries in any age group. The organs
primarily affected were in the abdomen rather than in the chest,
or in the lymph glands (nodes) elsewhere in the body.
I had been used to seeing younger patients in the United
States with Hodgkin s disease (a type of lymphoma) and other types
of lymphoma, with swollen lymph nodes in the neck or armpit, or
maybe enlarged lymph nodes, detected by x-ray, in the mediastinum
--that space in the middle of the chest occupied by the heart,
trachea, great vessels, and esophagus.
But in Saudi Arabia we were seeing people roughly the same age
with lymphoma, seemingly confined to the abdomen- -more difficult
to diagnose. And the disease was particularly more difficult to
diagnose because of confusion with abdominal tuberculosis also
common among Saudis. So here you had two diseases with
overlapping manifestations one could be initially mistaken for
Julius W. Taylor, "Cancer in Saudi Arabia," Cancer. Vol. 16, 1963.
84
the other. The only way you could make the distinction, at times,
was by exploratory surgery, with biopsy of diseased tissue.
Hicke: How did all of this affect your making a diagnosis?
Gelpi: With a high index of suspicion, the diagnosis still had to be
confirmed either by finding tuberculosis organisms or by finding
in diseased tissues the typical cell pattern indicating that the
patient had lymphoma. The importance of this distinction, of
course, lay in choosing the right treatment. Because people with
tuberculosis could be treated effectively with the antimicrobial
agents available at the time. With lymphoma, the choice of
treatment was much different, and more complex. Many could have
been treated with x-ray, but we did not have therapeutic x-ray
available in Aramco medical facilities. We had only diagnostic x-
ray. So people with lymphoma would have to be referred out of
Kingdom. I m not sure that radiation therapy (x-ray, et cetera)
was available either in Riyadh or Jiddah at the time. We could
treat them with chemotherapy, but this was by no means always as
effective as x-ray.
Hicke: Do you have any idea why they were developing this type of cancer?
Gelpi: We know that a similar high incidence of lymphoma had been
reported from other third-world countries in North Africa and the
Middle East. In fact, someone coined the term "Middle East
lymphoma" to describe this disease. Some of the important work on
this problem, with resulting publications, was being carried out
elsewhere while I was investigating abdominal lymphoma in Saudi
Arabia.
The prevailing notion then was that multiple, recurring,
intestinal infections of various typesbeginning in infancyled
to a marked stimulation of those tissues responsible for the
immune response in the gut and in the lymphatic system associated
with the intestinal tract, with of course increased proliferation
of immuno- competent cells. Ultimately this growth would get out
of control, lose its self -regulating characteristics, and turn
into cancer. If you look hard at third-world countries, world
wide, this problem is probably there waiting to be discovered.
For it is not likely to be unique to Africa or the Middle East,
because lifelong recurrence of intestinal infections is a
universal problem in developing countries.
Hicke: What s happened to this research on abdominal lymphoma?
Gelpi: I think that the excitement generated by this and other exotic
diseases tends to die out. I also think that what the
identification of this disease, abdominal lymphoma, may have done
85
is to encourage trials of new sorts of treatment. And there is
evidence that the prognosis for patients with abdominal lymphoma
may be better than that for patients with the types of lymphoma
encountered in Western populations. But I don t believe that
there have been any major breakthroughs in this area over the last
twenty years.
Hicke: Is it a fairly high percentage of people who recover?
Gelpi: I can t tell you exactly; but the combinations of x-ray and
chemotherapy may be more effective than one would expect with
lymphoma, generally.
Hicke: Once again, were these mainly Saudis who were infected?
Gelpi: All were Saudis. This was not a problem among European or
American expatriates. It was strictly a problem endemic to Saudi
Arabia. And actually, I don t think we were seeing it among other
people from Middle East countries --Lebanon, Jordan, Syria, Egypt-
living in Saudi Arabia. But I wouldn t go beyond the presumptions
I had at the time the report on this problem from Saudi Arabia
reached publication.
Conference in Shiraz , Iran: G6PD Deficiency and Favism
Hicke: Meanwhile, you still had your regular duties?
Gelpi: Well, of course I was taking care of patients and doing a lot of
administrative chores. It was a period in my life of intense
activity.
Hicke: Yes, I can see that.
Gelpi: Another area of interest: in the early sixties I went to a medical
conference in Shiraz, Iran. And at this conference, the
pathologist at the university medical center in that city--Nemazee
Hospitalpresented a paper on red cell glucose-6-phosphate
dehydrogenase (G6PD) deficiency in the Iranian population living
in the city or nearby. G6PD is an enzyme which protects the red
cell membrane from oxidation. A deficiency of this enzyme leads
to interaction between red blood cells and a component of fava
beans--a major dietary item in the Middle East.
It seems that fava beans have a particular substance which
damages the red cell membrane, when the red cell is deficient in
G6PD, and results in rupture of the cell membrane. Many red cells
86
break down in this fashion, releasing their content of hemoglobin.
And this may lead to the rapid onset of anemia, release of a large
amount of free hemoglobin into the blood and ultimately into the
urine. The loss of red cells and the flood of hemoglobin passing
into the urine may result in severe anemia, kidney failure, and
death. Is it common? Favism, as it is sometimes called, is
widespread and well known among Mediterranean populations. But as
far as I know, favism and G6PD deficiency had not been previously
reported in the Middle East until this particular conference, at
which time it was discussed by the pathologist, Dr. James Bowman.
Hicke: Do you have any idea what year this was?
Gelpi: This would have probably been 1960 or 1961. Needless to say, it
took me a mere instant to at least consider the possibility that
if this condition was prevalent in central Iran, where people ate
fava beans, it may also be prevalent in the oases population of
eastern Saudi Arabia, where they also eat fava beans.
Hicke: Oh, they do?
Gelpi: The fava bean is a dietary staple. And the question then was, why
are we missing this condition?
Hicke: You didn t have it then?
Gelpi: It turned out that we did have it, and that we had been seeing
children with favism in our emergency room and on our hospital
pediatric service probably for as long as DHC had been open for
business. A parent would bring in a very pale, sick child, who
would be admitted to the hospital for severe anemia. Nobody was
asking the question, what did the child have to eat the day
before? I came back from the meeting in Shiraz with a messianic
message, which was: Let s start looking at our admissions,
particularly on the pediatric ward, to see if we are getting cases
of favism. The clue was, and is, the presence of hemoglobin in
the urine. Well, we were getting cases of favism, except the
diagnosis had been missed.
The next step was to go out and see how common G6PD deficiency
was, and where it was. In the oasis population? How might one
best survey the oasis population? As a supernumerary with the
annual malaria survey team, tag along I did, with my capillary
tubes for collecting minute blood samples and my lancets, and I
found that eastern Saudi Arabia has one of the highest
concentrations of G6PD-def icient people in the world.
Hicke: And nobody knew it before you arrived with your lancets?
87
Gelpi: No. In some villages I found that almost 40 percent of the male
population had the red cell defect, G6PD deficiency; which meant
that almost the same percentage were at risk from eating fava
beans .
Hicke: Because it s genetic?
Gelpi: Right. This defect is a sex-linked characteristic, which means
that the gene responsible is on the X chromosome. Thus males-
having only one X chromosomeare at risk from having the defect,
while the vast majority of females are only carriers. And these
carriers are not at risk, because they carry a normal gene on the
other sex chromosome. The rare female with a double dose of the
G6PD deficiency gene, that is, a defective gene on each X
chromosome, is at risk.
Hicke: So females would pass it on.
Gelpi: Yes, they pass it on to children of both sexes. And as far as the
G6PD-def icient males are concerned, they are not only at risk from
eating fava beans, but they are also at risk from certain
infectionswhich may trigger red cell damage in the presence of
the enzyme defect and from certain commonly used medications.
One in particular, primaquine, is known to bring about hemolysis
(breakdown of red blood cells) in G6PD-def icient red cells, and it
is commonly used to treat and prevent a certain type of malaria.
Hicke: Is it the same as quinine?
Gelpi: No. It s actually a synthetic which works somewhat like quinine.
So, given a situation in which you have a Saudi with vivax (one of
four malaria species) malaria and you decided to treat him with
primaquine, not knowing whether the individual is G6PD-def icient
or not, you have placed the patient at risk of a hemolytic
reaction to the drug. And for those Saudis who sometimes were
treated with primaquine and would subsequently become anemic, we
now had an explanation.
Hicke: Was this commonly known about primaquine?
Gelpi: Yes, it had been; the initial work with primaquine had been done
with G6PD-def icient Afro -Americans.
Hicke: So what did you do?
Gelpi: First of all, I was able to find out how prevalent the enzyme
defect was in the Saudi population, both within and outside of the
oases. Next it was possible to alert our medical staff to the
possibility that unexplained, severe anemia in Saudi children was
88
likely to be due to favism, not malaria or iron deficiency; and
that affected children should not again be exposed to fava beans.
Saudis should avoid certain medications, which in the presence of
G6PD deficiency might cause red cell destruction and acute
hemolytic anemia. Doctors should begin to think about the
possibility of G6PD deficiency as an explanation for otherwise
obscure anemias in adult Saudis, particularly if those individuals
were taking medications which interact with G6PD-def icient red
cells .
I believe that Aramco doctors began to appreciate the extent
of this problem. I m not so sure about doctors in other medical
facilities scattered throughout the Kingdom. Of course this
information was published and added to increasing knowledge about
the extent of G6PD deficiency in various populations throughout
the world. It s clear that the condition is common throughout the
Middle East.
Hicke: How do you go about alerting others through publications?
Gelpi: I believe that medical journals serve as the most important
conduit for transmitting this type of information to health care
professionals, including public health authorities. And since I
left Saudi Arabia, there have been many additional publications
describing G6PD deficiency in various parts of the Kingdom; so it
is clear that the extent of the problem is well known. I have to
assume that over the past thirty years most all of the health care
providers in Saudi Arabia have a fundamental understanding of G6PD
deficiency, favism, and drug-induced hemolytic anemias in G6PD-
def icient individuals.
Hicke: What actually happens when someone eats fava beans?
Gelpi: In a G6PD-def icient individual, red cell membranes are ruptured,
and a large proportion of red cells may be destroyed in just a few
hours. The large amount of hemoglobin released from the damaged
red cells, together with the red cell debris, may cause secondary
problems because of kidney damage. But the effects of the acute
anemia from the loss of normal circulating red blood cells can be
catastrophicparticularly for the elderly, who may have some
other debilitating conditions.
Hicke: How long does this last?
Gelpi: The anemia lasts until the bone marrow can replace the lost red
cells. If the victim is iron deficient to begin withas many
individuals in third world countries arerecovery may be delayed,
and it may be weeks before the red cells reach levels comparable
89
Hicke;
Gelpi:
Hicke:
to that which existed before the onset of the acute anemia. With
adequate iron stores, the lost red cells may be replaced in a
matter of days.
And why were you looking for G6PD deficiency in children?
Because they were more likely to be severely affected. The
effects of severe anemia would be more apparent. And iron
deficiency plus malnutrition as complicating factors would tend to
aggravate the symptoms and signs of red cell loss associated with
G6PD deficiency. And this would be more likely to tip the balance
in favor of hospitalization.
You talk about people known to have this deficiency,
some way to test for it?
Is there
Gelpi: I employed a simple test, which involved using only a drop of
blood collected in a fine, capillary tube. The test consists of
detecting red cell G6PD by a specific chemical reaction: a
positive reaction indicates the presence of the enzyme. There are
more sophisticated tests available, requiring larger amounts of
blood, which provide more quantitative information about the
enzyme rather than a measure of whether the enzyme is present or
absent. These tests also provide information about several types
of genetically distinct enzyme deficiency. For example, African
blacks and African Americans have a mild type of G6PD deficiency--
that is, they are partially enzyme deficient. In the Middle
Eastern type, there is complete absence of G6PD activity. Blacks
have what is called the B type of G6PD deficiency, whereas many
people with the Middle Eastern variantwhat we call G6PD
Mediterranean, or A-G6PD deficiency. Saudis have the A- variant.
A few carry the normal B+ variant. So I found that Saudis had the
more severe type of G6PD deficiency, which led to more severe
effects on their red cells when exposed to sensitizing drugs.
Hicke: Is there anything you can do to warn people that have G6PD
deficiency?
Gelpi: Both on an individual and family basis it was possible to provide
counseling. However, I have no idea what has been done throughout
the Kingdom in terms of health education about the prevalence and
risks from G6PD deficiency. I have to assume that there has been
some publicity, based on the number of publications which have
appeared in various biomedical journals over the past thirty
years. And there are investigators in Saudi Arabia who are still
doing surveys. I see the citations about this work in my reading.
Hicke: Maybe testing for it has become routine?
90
Gelpi: I think it probably is. The condition shouldn t be a stranger to
Saudi health care professionals any longer.
Sickle Cell Trait and Sickle Cell Disease
Hicke: What s next?
Gelpi: Well, we could jump ahead to sickle cell disease; but Dr. Richard
Perrine and a group from Oxford picked up where I left off,
carried out a lot of work, and published a number of papers on
sickle cell disease. However, just before my arrival in Saudi
Arabia, an anthropologist working for Aramco, in collaboration
with a British investigator who was an expert on the worldwide
distribution of human blood groups, carried out a survey for blood
groups and incidentally, the sickle cell trait--in the Eastern
Province of Saudi Arabia. Their important findings included the
observation that the sickle cell trait was quite common in the
oases populations. The work was published either in the Lancet or
the British Medical Journal; I don t remember which. But it was
an article which caught my attention soon after I arrived in Saudi
Arabia.
The sickle cell trait is common in Africa, and it is found in
about 8 percent of Afro-Americans. But there are places in
equatorial Africa where it occurs in more than 20 percent of the
population. This trait is a genetic marker, and in itself
harmless, except under most unusual circumstances, such as at high
altitudes. But sickle cell disease is another matter. Here we
have two genes affected- -one inherited from each parent. When
there are two genes for the sickle trait, the affected person has
sickle cell disease. And so the early village survey told me that
there might be not only a high proportion of oases inhabitants
with the trait, but also an alarming number with sickle cell
disease. But if that were so, where was this disease? We weren t
seeing it in our hospital or our clinics. The answer was there;
we just weren t paying attention.
Adult Saudis seen in our clinics for a variety of medical
problems, or hospitalized for, say, appendicitis, would be noted
to have a mild anemia. The anemia was usually ignored in favor of
dealing with another, more important medical problem. Bearing in
mind that blacks and Afro-Americans with sickle cell disease were
readily diagnosed, because the severity of their anemia and other
complications immediately called attention to the possibility of
sickle cell disease, we ought to be seeing patients with
91
comparable illness due to this disease. Why weren t we seeing
this? Were the sickest ones dying off in infancy?
One day I happened to see a Saudi, one of these people with an
unexplained, mild anemia who was referred for another medical
problem. On examination I found that he had an enlarged spleen.
Which prompted me to wonder if the enlarged spleen and the anemia
might be related. Well, of course this combination could be due
to malaria. But what about the possibility of sickle cell
disease? Upon testing he was found to have the disease.
But the medical literature at that time advised us that
African blacks and Afro-Americans had severe illness associated
with sickle cell disease, and that their spleens were affected in
such a way as to become smaller, almost to disappear. On the
other hand, every Saudi patient whom I saw with an enlarged spleen
was destined to be diagnosed eventually with sickle cell disease.
And most adult Saudis with unexplained anemia--later found to be
the result of sickle cells diseasewhen carefully examined, were
found to have enlarged spleens.
So here we had people with sickle cell disease which was
fundamentally different than the same disease among African blacks
and Afro-Americans. Most were without symptoms, and sickle cell
disease was an incidental diagnosis. But we had still only
scratched the surface; for some of these patients would appear in
our clinics and emergency room complaining of various aches and
pains. The pieces of the puzzle began to fit together.
It s well known that Afro-Americans and African blacks with
sickle cell disease have recurrent bouts of pain, sometimes very
severe, in joints and in the abdomen. And the cause of this is
the presence of deformed, sickle cells under conditions of low
oxygen tension in the small blood vessels. The deformed cells
become compacted and obstruct small arteries and veins, causing
bone and abdominal pain. So many of our Saudis with previously
unexplained pain began to fit into the picture. For often they
would be seen with this complaint, thought to have possible
appendicitis, peptic ulcer, or arthritis depending on the
location of their painand after some pain relief with
medication, they would be released, only to return again with
similar pain, perhaps at a different site. They were having the
same pain, in the same location, as blacks, only the pain was
almost invariably milder in comparison.
So the picture emerged of the typical Saudi with sickle cell
disease: a reasonably healthy young male with a hemoglobin around
11 or 12 grams/ 100 ml. --abnormal, because the usual level is
around 14 to 16 grams/100 ml. --an enlarged spleen, and an
92
occasional visit to our hospital or clinics because of joint or
abdominal pain. Whereas a young Afro-American, with presumably
the same disease, had a hemoglobin level of 7 to 8 grams/ 100 ml.,
was having disabling bouts of pain, felt miserable all the time
because of chronic anemia, and had a very limited life span
because of certain infections and other life-threatening
complications .
Hicke: They had a different kind of...?
Gelpi: They had a different kindor a different expressionof this
disease. We know now that there are at least two mutant genes
responsible for sickle cell disease. At the time we began
research on this condition in Saudi Arabia, I believedand so did
many other investigators that there was only the African type.
We now know that there is a type peculiar to the Middle East
genetically distinct which produces the same phenomenon of
sickling in the red cell, but to a lesser degree, resulting in
less severe symptoms. My original suspicion was that the sickle
cell gene was imported to Arabia from Africa, and that the mild
disease found in Saudis was due" to other, protective factors which
shielded sickle cells from becoming deformed. But we now believe
that an independent mutation occurred in the oases populations of
Eastern Arabia or some adjacent location perhaps thousands of
years ago. And we have also learned that in fact, the African
sickle cell trait is found in western Saudi Arabia, and that
homozygous individuals that is, people with both genes affected-
have severe disease.
I was wrong about the source of the sickle cell gene in
eastern Saudi Arabia; but I was right about the protective factors
which suppress sickling, and thus in part may be responsible for
ameliorating the expression of sickle cell disease in Saudis. One
of these factors is almost certainly fetal hemoglobin, or
hemoglobin F. Others may be the thalassemia traits common in
Saudis and G6PD deficiency.
But you also have a Darwinian explanation for the occurrence
of the sickle cell trait in the Saudi population. As a random
mutation, the sickle cell trait, like so many others, should
simply disappear or be represented in an extremely small
proportion of people, unless it confers some special advantage.
There is now a consensus that the sickle cell trait, together with
certain other genetic traits which affect red blood cells, makes
red cells more resistant to malarial parasites. Among these
traits is the hereditary absence of the Duffy blood group. The
sickle cell trait protects against falciparum malaria and the
Duffy negative status protects against vivax malaria. In fact,
the Duffy blood group antigen is the receptor for the vivax
93
parasite on the red cell. Back in the sixties, it was found that
most Afro-Americans were Duffy-negative, and that almost all
African blacks were Duffy-negative. But at that time we had no
idea about the significance of this except that the Duffy-negative
condition was a pretty reliable genetic marker for identifying
African gene flow to other populations, that is.
There are two Duffy gene types, A and B, expressed in various
combinationsAA, AB, BB, B-, A-, and 0- or absence of both genes.
Someone came up with the idea that the Duffy-negative state must
confer a selective advantage; but how? It was also well known at
the time that African blacks were mysteriously spared from vivax
malaria in endemic areas, although many suffered from falciparum
malaria. With just a little more serendipity it was established
that the absence of Duffy antigens on their red cells protected
Africans from vivax malaria.
Back to Saudi Arabia: it occurred to me that if sickle cell
disease was prevalent in Saudi Arabia, and if the sickling trait
came from Africa, which I believed it undoubtedly did, then there
must be another genetic market which would prove the point. Why
not look at the Duffy blood group genes in the Saudi population
and determine the degree of African admixture? It turned out that
between 70 and 80 percent of Saudis in the Eastern Province lacked
the two Duffy antigens.
So not only were they protected from falciparum malaria by the
presence of the sickle cell trait, perhaps somewhat by G6PD
def iciency for believe it or not, that is now believed to be a
protective factor but they were also protected from vivax malaria
by the absence of Duffy red cell antigens in a high proportion of
the population. Over many generations, the oases Arabs had
developed a unique pedigree composed of multiple genetic traits
which made their red blood cells resistant to two species of
malarial parasites.
Hicke: I ve read someplace that there were black slaves brought into
Saudi Arabia. That s obviously within recent history, speaking in
Darwinian terms.
Gelpi: Within the past 1,500 years let s say since the beginning of
Islam 1 there was a flourishing slave trade originating in East
African ports lasting well into the late 19th century. And there
may have been a trickle well into the 20th century.
was established by Mohammed (570?-632) and spread throughout
the Middle East. Within a century after Mohammed s death, an Arab Muslim
empire extended from Spain across central Asia to India.
Hicke: And was that a factor in all of this?
Gelpi: Here we have a convergence of historical and genetic evidence to
support the theory that there was a great deal of African
admixture into the populations of eastern Arabia. And I thought
that this was the explanation for the presence of the sickle cell
trait and sickle cell disease. But I concluded that the mild
expression of this disease had nothing to do with the possibility
of two different sickle cell genes, but that it was the result of
the interaction of other red cell genetic markers fetal
hemoglobin and the thalassemias--on the red cells containing
hemoglobin S (sickle cell hemoglobin). Yes, they tend to have
elevated levels of hemoglobin F, which is protective. And many
have associated thalassemia traits, which may also be protective.
But they also have a fundamentally unique type of sickle cell
hemoglobin.
Hicke: Which they did not get from blacks.
Gelpi: Which they did not get from blacks. But there is some of the
African type of sickle cell trait and disease in Arabia, notably
along the Red Sea. And we now know that the Saudi variant of the
sickle cell trait has spread to other populations in the Middle
East, probably fartherto Iran, India, Syria, possibly as far as
Greece. For we have known for years that there is a relatively
mild type of sickle cell disease in southern Turkey among the Eti-
Turks (immigrants from Syria), and in certain areas of Greece and
in India.
So the sickle gene has spread widely from the Middle East, as
it has from Africa. When I was working on the problem of the
trait and the disease in Dhahran, I exchanged correspondence with
some Israeli researchers interested in this problem within their
Arab population. And they indicated that yes, the sickle cell
trait was present, that the expression of sickle cell disease was
mild, and that Israelis even if native born did not have the
trait.
Beyond all this it was possible to show that having sickle
cell disease as a Saudi was compatible with a long life and
relative freedom from most of the complications associated with
this disease in America and in Africa.
When I finally left Saudi Arabia and Aramco employment, I
listed all the patients I had followed with sickle cell disease.
There were probably fifty or sixty. This was a good group to
follow for a longer period, for follow-up family studies. Dr.
Perrine and his colleagues from Oxford picked up where I left off,
extended the studies, acquired new patients with the disease,
95
amplified some of the testing which had been done before, and were
able to confirm that the Saudis had benign sickle cell disease,
and that a lot of the complications characteristic of the disease
in Africa and America were not occurring in Saudis. Much of this
work has been published, and Dr. Perrine knows a good deal more
about it than I do.
Hicke: You keep talking about malaria as a basic problem. Some of the
things that you detected were protecting against malaria. And
yet, when I first heard of malaria there, when you told me there
was malaria in Saudi Arabia, it seemed hard to believebecause
it s a desert. You don t think of water-based diseases there.
Gelpi: That s true. Most of Arabia is free of malaria because most of
the country is a desert. But the oases are rich, verdant areas
with an abundant water supply from the wells in the area. It s a
totally different environment.
Hicke: I guess what I m saying, then, is: would you notice considerable
difference between the Bedouins of the desert, for instance, and
the people who lived in the oases? You ve been talking mostly
about the oases.
Gelpi: As you might have guessed, evolutionary trends in geographically
separate populations are likely to be different. There would be
major genetic differences. And there are among Saudis. There are
very low frequencies of G6PD deficiency and sickle cell trait in
the Bedouin. I don t know about the Duffy blood groups, but I
imagine there would be similarities because of the African
admixture. But in any case, these populations have selected for
the presence or absence of these traits over many generations.
Hicke: Did you work with the Bedouin at all?
Gelpi: Actually, in many of the town sites in eastern Arabia there is
some representation of Bedouins. They are Sunni Muslim. They ve
been attracted to the oases for a variety of reasonsemployment ,
commerce, and so on. They ve become assimilated into village
life, but still maintain both their religious and cultural
identity, which distinguishes them from the Shi ite groupthe
predominant sect in the oases, particularly in the Qatif oasis
complex closer to Dhahran, as compared with Al Hasa oasis, which
is much farther to the south. But there, the red cell markers
which we have been discussing are much less prevalent among the
Sunni inhabitants, even though they have resided there for many
generations.
Hicke: There are religious differences, but also cultural?
96
Gelpi: The Shia and Sunni have different cultures--dif ferent attitudes
about employment, social status, different marriage customs, and
so on. But there are these genetic dif ferences--a matter of time
and cultural identity.
Hicke: And environment.
Gelpi: Yes.
Schistosomiasis
Hicke: I also wanted to ask about Schistosomiasis.
Gelpi: I d like to spend some time on it, if only to point out the
valuable work that was done on this problem by one of the Aramco
people. I won t go into the details of the disease except to say
that we saw evidence of Schistosomiasis in Arabs who came from
other regions of Saudi Arabia, not people who were indigenous to
the Eastern Province. The reason is that this disease is another
type of worm infection which involves the blood vessels of the
intestinal or urinary tract. Two different types of worm infect
the intestinal veins, one type affects the veins from the urinary
tract. That intestinal type, with which we are concerned, is
called Schistosoma mansoni.
The cycle of infection progresses as follows: there is a snail
vector and an alternation of generations between the worm which
infects humans and that which infects the snail. The snails carry
what we call the larval stage; the larva emerges from the snail as
a free- swimming form which infects man by penetrating the skin and
ultimately arriving in the venous system of the lower intestine,
where they mature to adult worms. Adult female worms release
eggs, which find their way into the membranes lining the
intestinal tract and are excreted in the stoolideally into
water. Here a new variant of the worm emerges again, as a free-
swimming form- -which seeks out the specific snail serving as
intermediate host to complete the cycle. A similar cycle of
events occurs with S. hematobium; but in this case, a different
species of fresh-water snail is involved; the larval form-
infectious for humans--ends up in the vascular system supplying
the lower urinary tractprimarily that of the urinary bladder.
And as you might imagine, the eggs are released into the urine and
find their way into water to hatch.
The complications from repeated infections of this type result
in scarring of the intestine or the bladder. But in the case of
97
S. mansoni, many of the eggs are carried downstream to the liver.
Almost all of the veins from the intestinal tract drain into the
liver, which acts as a huge metabolic factory, manufacturing by
products from the incoming load of proteins, carbohydrates, fats,
and vitamins. The complications which we saw from S. mansoni
infections indirectly resulted from scarring of the liver around
the entering veins, called portal veins. This scarring compressed
the tiny portal veins, increasing the pressure within the system.
Hicke: The scarring would be a building up of tissue which would...
Gelpi: Which would constrict the blood vessels. Therefore, it would
raise the pressure in the veins, which would be transmitted
throughout the portal system. The effects of this upon the veins
in the stomach and lower esophagus resulted in varices--very
fragile varicose veins-- just under the lining of the esophagus.
The varices would rupture; and so we would see people with the
complications of bleeding from the lower esophagus and upper
stomach. Otherwise, these victims were not too severely affected
by their disease.
Since schistosomiasis was not endemic in the Eastern Province,
we were not seeing the disease in locals. Dr. Ivan Alio, who was
an epidemiologist assigned to Aramco s Preventive Medicine
division, did a large survey in the early sixties which mapped the
epidemiology of the disease throughout Saudi Arabia. It turned
out that all of our cases were coming from western or central
Saudi Arabia. This was because the snail vectors, which were the
essential intermediate hosts, were not present in the fresh water
sources in the Eastern Province. I could digress and talk more
about the disease elsewhere in Saudi Arabia, but because of its
technical nature, I would prefer to defer it for editorial
commentary.
Hicke: What motivated Dr. Alio to go into this?
Gelpi: He and others were asking certain questions: does this disease
exist in the Eastern Province? Is there a risk to the local
population from imported schistosomiasis? How much is this risk?
And it was important to know the distribution of the disease
elsewhere in Saudi Arabia in order to anticipate the possibility
of schistosomiasis among Saudis from various parts of the Kingdom
already employed by Aramco, or applying for employment.
Knowing that the snail vector did not exist in the Eastern
Province answered the question concerning whether or not
schistosomiasis could be native to the Eastern Province, or could
be imported. And this is the way it turned out. Dr. Alio s
research, and its resulting publication, constitute a monumental
98
piece of epidemiologyprobably the best example of its kind-
showing the distribution of schistosomiasis in the Kingdom. It
was published as a soft-cover, limited edition from a printing
source in Riyadh; and there are not many copies in existence. But
I managed to abstract the results of the study from a copy in my
possession. This is a very important contribution.
Hicke: Is Alio s work still being used?
Gelpi: I have no idea what sort of control measures for schistosomiasis
have been developed in Saudi Arabia. But I know that there have
been additional publications on this disease in Saudi Arabia from
other sources.
Pulmonary Tuberculosis
Hicke: I have two more diseases to ask about: hepatitis and pulmonary
tuberculosis.
Gelpi: Tuberculosis, in many ways, was pretty much the same disease you
see in socio-economically deprived populations in the United
States. We were seeing tuberculosis in Saudi Arabia at a time
when the country was rapidly changing into a world-class
technocracy of the sort you might expect in Europe and elsewhere
in the West.
Much of the disease in Saudis was typical pulmonary (lung)
tuberculosis that you might see anywhere. But we were also seeing
abdominal tuberculosis, involving the same organs affected by
lymphoma, which I discussed earlier. But we also saw tuberculosis
involving the lymph glands of the neck- -proportionately more than
you would expect to see in the United States.
Treatment plans included the drugs which were then available
in the United States: streptomycin, para-aminosalicylic acid
(PAS), and isoniazid (INH). These drugs were widely used until
the seventies.
We now have additional, newer drugs, to combat resistant
strains of the tuberculosis organism. How the disease is being
managed in Saudi Arabia at this time, I have no idea. But the
original combination of streptomycin, PAS, and INH was very
effective for us in treating the disease in Saudis.
Hicke: Is tuberculosis dying out?
99
Gelpi: I believe that tuberculosis is disappearing in Saudi Arabia,
because I think that the standards of public health and access to
high quality health care have improved remarkably over the past
twenty or thirty years. But really, there s not much to add to
the tuberculosis story, except to emphasize the confusion between
abdominal tuberculosis and abdominal lymphoma which may make the
diagnosis so difficult.
Hepatitis
Gelpi: Getting on to hepatitis: I think I can summarize by saying that
the disease in Saudi Arabia, as it is in much of the world, is
caused by three main viruseshepatitis A, B, and C. At the time
when I was looking at the disease in Saudis, we were not able to
make these distinctions; and there is even another virus-
hepatitis E--and I ll touch on that a little later. We had not
yet divided the hepatitis virus family into four sub-types.
And it wasn t until the seventies that we really started to
make headway in identifying the different hepatitis viruses. But
at that time we knew how to distinguish viral hepatitis from
hepatitis due to other causes, such as drugs which damage the
liver. Given someone who was sick, jaundiced, who had abnormal
liver function tests, and who had someone else in the family with
hepatitis, it was not hard to make the diagnosis. But we didn t
actually isolate the virus for purposes of diagnosis because of
technical limitations, nor were we able to detect the virus
indirectly with blood tests which measure antibody against the
virus. And as yet, we were unable to make the distinction between
the virus sub-types.
So, we were seeing Saudis with acute liver disease, most
likely due to viral infection, and probably not due to drugsfor
none of the hepatitis victims were on long-term medications. Most
of these people had mild illness, and many did not need to be
admitted to the hospital. There were exceptions.
Women seemed to be more seriously affected by hepatitis, and
were often admitted to the hospital because of the severity of
illness. And those admitted were more likely to die than males of
the same age with the same disease. And of those women who died,
most were pregnant or had recently delivered a baby. Those who
were pregnant, and who succumbed, were likely to be in the third
trimester of pregnancy. The point was, given a young Saudi woman
with hepatitis who would soon give birth, there was a high
probability of a fatal outcome. Why? But the problem was even
100
more complicated. In pregnant women, hepatitis was associated
with a high rate of fetal loss, both spontaneous abortion and
miscarriage.
There wasn t any obvious explanation at the time; but there
were reports of fatal hepatitis during pregnancy coming from other
parts of the worlddeveloping countries an indication that the
problem was widespread. There were papers from Algeria and
elsewhere in Africa, from Iran, and from India indicating that
viral hepatitis in pregnancy was often fatal. Strangely, viral
hepatitis during pregnancy in Western countries, industrialized
societies, was not particularly risky. Why this difference?
There must be something about third-world social or cultural
conditions that makes the disease worse in pregnant women. What
could it be? Diet probably; the fatalities were due to
malnutrition. Wrong. All other things being the same, hepatitis
in Saudis, no matter how well-nourished the victims appeared, was
often fatal in pregnancy.
Hicke: Much more so than in Western societies?
Gelpi: Much more so. We now think we have an explanation- -not because of
the observations I made in Saudi Arabia, but because we have found
the culprithepatitis E viruswhich causes epidemics in
developing countries, but also causes sporadic cases of hepatitis.
And it has been consistently associated with high fatality among
pregnant women- -particularly those at term, those women who are
about to deliver or have just delivered their babies. This
infection is almost essentially water-borne. But we really don t
know why this virus is so dangerous during pregnancy. So I can
end up by saying that hepatitis A, B, and C is probably much the
same in both men and in women, regardless of pregnancy.
It has been suggested that a woman s immune response changes
during pregnancy. Not surprising, otherwise if it didn t change,
she would reject the fetus, regarding it as being a foreign body
in the uterus, but this doesn t happen very often. But we are
beginning to think that with immune tolerance of the fetus, there
may be tolerance for other, unrelated foreign material, such as
the hepatitis E virus.
Hicke: That s really amazing! Are there other instances of such
tolerance?
Gelpi: I can t tell you too much about it. Much of what I have told you
is speculation the sort of thing that medical scientists do when
they re seated around a conference table engaged in intellectual
browsing. We only know that the immune response in pregnancy is
different. And we think that the pregnant woman, with occasional
101
Hicke;
Gelpi:
Hicke:
Gelpi;
exceptionsobviously, there are spontaneous abortions, now and
thenidentifies the fetus as self, in spite of the fact that only
half of its genetic makeup is derived from its mother. But the
maternal immune system identifies this thing, this parasite, this
fetus, as self, rather than non-self. Even though the father s
genes are there, creating slight differences between the mother s
tissues and those of the fetus, the mother s immune system says,
"Hey, this is me."
But there may be alternative, totally opposite, explanations
for the effects of the hepatitis E virus on pregnancy and upon the
pregnant woman. Maybe this virus can run rampant and kill its
victim simply because of the large viral load causing large
numbers of sick and dying liver cells in the presence of a blunted
immune response. But maybe it s the other way around; the immune
response may be so vigorous that it is worse than the disease.
The damage that s done fighting the virus leaves the liver in
wreckage, which is obviously worse than simply contending with a
rapidly multiplying virus.
There are various reasons for believing the first hypothesis,
based upon what we know about hepatitis from other causes. With
other types of viral hepatitis, the virus may be fairly well
tolerated, despite the fact that the virus is proliferating and
destroying liver cells so well tolerated that it leads to chronic
infection which takes years to disable or kill its victim. That
summarizes the problem of viral hepatitis, as well as I can
express it.
But tell me exactly what you did, your part in all of this.
My part was to look at every Saudi woman with hepatitis in the
hospital. I asked to be called on all admissions in order to
document the severity of disease, to select certain tests which
would tell us the likelihood of survival or imminent demise, so
that we could evaluate the effects of supportive care and specific
medications on the course of the disease. We wanted to save these
people, if possible, by identifying those who were critically ill.
It seemed that the best test available for indicating an
unfavorable outcome was the prothrombin timea measure of one of
the components of the clotting cascade. If the prothrombin time
was abnormal (prolonged), this was almost certainly a death
warrant. All the women with significantly prolonged prothrombin
times died.
So they don t know if there s some remedy.
Based on what we know from multiple reports on the management of
fulminant (explosively severe) hepatitis from many sources in the
102
United States, Canada, and Europe, we have learned that
adrenocortical steroids don t work. Although at the time they
were first employed to treat potentially fatal hepatitis, they
seemed like rational choices to suppress an intense immune
response accompanied by marked inf lammation--if one believes that
the immune response is worse than the infection itself. Whether
or not supportive care- -intravenous nutrition and fluids,
primarilymakes much of a difference, it s hard to tell. In a
highly sophisticated, tertiary care medical center, many of these
patients would be candidates for liver transplants.
I don t know whether or not fatal hepatitis during pregnancy
is still a significant health care problem in Saudi Arabia. I
have no reason to think that much has changed, except that the
overall incidence of viral hepatitis has probably dropped to a
significant degree, and the incidence of fatal hepatitis has
dropped proportionately. But I went back after the first study of
hepatitis complicating pregnancy and began to look at the cases
that had accumulated over a period of five or six years following
completion of the original study and its publication. There was a
difference in mortality, with apparent improved survival in the
later group of patients with hepatitis. I have no explanation for
this. The patients may have been selected. Perhaps the strain of
virus had disappeared. Those who favor the theory that it was
socio-economic conditions and nutritional status which determined
the outcome would say, "See, living conditions are better; that s
why." But I don t think that s the explanation; it s too easy.
But that s the end of the hepatitis story.
103
V MEDICAL DEPARTMENT ADMINISTRATION
[Interview 3: February 5, 1996]
Reporting to Aramco Management
Hicke: Today we re going to talk about administration in the Medical
Department .
Gelpi: The Medical Department, now called Saudi Aramco Medical Services
Organization, or SAMSO, was more or less an independent entity
within the oil company administrative network. However, the
medical director consistently reported to a representative of
Industrial Relations, invariably an Aramco vice president. The
executive composition of Industrial Relations was continually
changing; so that the person to whom Aramco s medical director
reported was also changing. In the span of the medical director s
tenure, he might be dealing with three or four different IR
representatives .
Hicke: And these would be non-medical types.
Gelpi: They were definitely non-medical types, and all had to be
successively educated by our medical directors. This, I believe,
created a certain inertia in communications and interaction
between the Medical Department and the rest of the company. Of
all the dimensions of medical administration, this was the worst.
Internally, the organization of the Medical Department had a lot
to recommend it, and I had no quarrel with the organization of the
company outside of the Medical Department. The thread which bound
the Medical Department to the rest of Aramco had to be constantly
reinforced by repeated education sessions for each IR
representative .
Hicke: What kind of decisions would that person be expected to make?
104
Gelpi: There were three major areas of concern. The first was obviously
financial: how much it cost to run the Medical Department year
after year. The second had to do with how Aramco s Medical
Department was involved with outside agencies, both within and
outside of government --because as you already know, Aramco was not
only providing medical services for its employees and their
dependents, but also for many people who had nothing to do with
the company.
The third area involved the expansion of health care; for as
the working population of Saudis and their dependents increased,
so did the requirements for health care. And much of this care
was provided for routine and rather trivial medical problems-
immunization, maternal-child health, well-baby clinics, minor
injuries, health education, and so forth. So both Aramco
management and the medical director had to think about the
possibility of providing health care in some other way, rather
than simply expanding Aramco facilities and hiring more health
care providers.
Hicke: So you really had to keep close contact with Industrial Relations?
Gelpi: There were weekly meetingsmaybe more often, depending on
circumstanceswith the IR representative about matters of mutual
concern. And the agenda of some of these meetings filtered down
to medical department rank and file in the form of lower level
weekly meetings attended by division and unit heads, and
memoranda.
Hiring
Hicke: What about hiring?
Gelpi: To a great extent, hiring was an initiative of, and at the
discretion of, Medical Department administration. But it
obviously had to fit into budget requirements for any given year,
and had to meet the approval of company management. As personnel
requirements were constantly changing, so was the Medical
Department budget. Those changes involving the addition of key
personnel needed advance planning to fit budget requirements.
Hicke: So that determined what slots might open, but who actually did the
interviewing? I think you ve indicated that a few times people
would go back to the States to interview.
105
Gelpi: This would most likely happen in conjunction with a scheduled
visit to the States. Typically, a Medical Department division or
unit head--say the chief of Surgerywould arrange to interview
one or more candidates for the position of surgeon while he was on
vacation or attending a meeting in the U.S. Depending upon
qualifications and personal impression, one of the candidates
would be invited to join Aramco.
Hicke: Now tell me about your participation in this.
Gelpi: As you know, when I joined Aramco in 1959, I was assigned to the
Medical Services Unit at DHC. Once again, this unit consisted of
Internal Medicine, General Practice, and Pediatrics. Several
months later, I became chief of Internal Medicine and chief of the
Medical Services Unit. And at that time there were two or three
other internists, two pediatricians, and perhaps as many as ten or
fifteen general practitioners assigned to various clinics and
inpatient services.
At the same time there were two district clinics with attached
infirmaries, and each had its own medical director, both reporting
to the medical director at DHC. Each had his own medical staff a
small number of general practitioners, some lab technicians,
nurses, an x-ray technician, and custodial people. At DHC we had
a much larger number of doctors, including specialists, an
administrative unit, a large nursing service, rather comprehensive
laboratory and diagnostic x-ray services, and a rather large
division of preventive medicine involved in all sorts of public
health activities, both within and out of the company.
Representative division and unit heads all reported to the medical
director at DHC.
Hicke: How did the pay of doctors and nurses compare with that of
commensurate jobs in the States?
Gelpi: I can t say much about the nurses, but I would say that doctors
pay compared favorably with that of generalists, pediatricians,
and internists in the States. This, of course, was back in the
late fifties and early sixties. For general and orthopedic
surgeons, for ophthalmologists, for otolaryngologists, for
radiologists, and for pathologists, I think that the pay was
definitely less than what they might expect in the U.S. at the
time. So there had to be other attractions to bring people out
who were in these specialties.
Hicke: What were these other incentives?
Gelpi: For some it was the opportunity to pioneer in the health care of a
developing countryfor at that time, despite its oil riches,
106
Saudi Arabia was a developing country. Even though it sprang
ahead during the seventies and eighties, becoming a modern,
industrialized country, when I was there, we were really seeing
medical problems typical of underdeveloped countries in Asia,
South America, and Africa.
No doubt there were other attractions. Some people were
especially interested in Middle East cultures. There were
unprecedented opportunities for world travel, because of Aramco s
generous repatriation and vacation policies, as well as travel
allowances. Aramco medicine had its appeal for those who were
interested in combining medical research with clinical practice,
who wanted to see exotic diseases in an exotic place, who wanted
to be on the cutting edge of progress in international health.
And so there was something for everybody.
Hicke: Was this pretty well promotedthe opportunities for travel,
research, and so forthbefore the people were hired?
Gelpi: I don t know, really, what individual basis each of my colleagues
had for coming to work in Saudi Arabia. As you know, at the time
I was recruited I had the opportunity to make my decision on the
basis of a visit to Dhahran before I accepted employment. And
within a couple of days it was possible to make up my mind that
Aramco offered great opportunities for both research and clinical
experience. That was the selling point, as far as I was
concerned. The opportunities for travel and to learn a lot about
the Middle East and its cultures were both secondary incentives.
Hicke: Did you do any of the actual recruiting?
Gelpi: I did some recruiting. I recall one trip I took with Dr. Taylor.
We went to Egypt either in 1961 or 62, both to Cairo and to
Alexandria. We were looking for additions to my medical services
and his surgical services unit. I don t recall if we came up with
any really good candidates. Dr. Taylor may remember more about
the trip than I, because besides recruiting, we had some
interesting adventures. I don t think we found the doctors we
were looking for. I didn t participate in recruiting beyond this,
except for inquiries about suitable people when I was in Beirut on
other business. Beirut was an attractive source for recruiting
because of the American University of Beirut [AUB] medical center
and its medical training, and because of the professional quality
of both Palestinian and Lebanese doctors. We were definitely
looking for interested graduates from AUB.
Hicke: Do you recall any that you got?
107
Gelpi: Over the years we got quite a few good doctors. Many would come
and stay for a few years, make a little money, and then either
return to Beirut or go to the United States for postgraduate
training in various medical specialties. Some eventually recycled
back to Saudi Arabia; a few returned to Lebanon and other parts of
the Middle East. Many remained in the United States.
Hicke: Would some of your recruits have been Americans?
Gelpi: No. In Beirut, these were Lebanese, Palestinians, maybe a
sprinkling of Arabs from neighboring countries, but mostly
Lebanese .
District Visits and Medical Education
Hicke: Would you tell me a little more about the educational program that
you had for doctors when you went to visit the districts away from
Dhahran?
Gelpi: As I suggested during an earlier interview, I believed that there
were two activities which might stimulate interest and raise
educational standards among Aramco physiciansat least in my
group, the Medical Services Unit. Therefore, I started weekly
visits to the districts--Ras Tanura and Abqaiq. These were
industrial and residential community complexes, each with its own
clinic and infirmary. These visits consisted of a noon lecture to
the doctors, based on a preceding case presentation, and some
consultations on one or more infirmary patients. Usually, there
were one or two people in the infirmary with medical problems
needing bed rest, but not severe enough to warrant hospitalization
at DHC. I would finish by seeing patients in the clinic, referred
for various problems. Most were Saudis. And I would alternate my
visits: one week it would be Ras Tanura, the next Abqaiq. I did
this for the eight years I resided in Saudi Arabia. I really
can t recall whether or not the district visits were continued. I
know that when I returned, during the seventies on locum tenens
basis, I was not involved with district visits, nor was I aware
that they had continued in my absence.
I guess that the visits had some value, both for the doctors
and the patients in the districts. I think that it brought the
doctors closer to DHC in spirit. We came to understand one
another s problems better. We got an appreciationat least I
didfor some of the difficulties faced by doctors at a distance
from DHC. And so I think that in the long run, it was a
beneficial arrangement.
108
Hicke: What subjects might be included in your lectures to the doctors?
Gelpi: A typical district visit might include the case presentation, on
ward rounds, of a patient with, say, hepatitis. This patient
would be presented by one of the district physicians; and then it
was up to me to give an extemporaneous lecture on hepatitis, which
I would do as best as I could under the circumstances. I never
knew ahead of time what was wrong with the patient; and that was
part of the game. So the excitement was generated by the
possibility that the doctors had come up with a diagnosis or
disease I hadn t read about. For me there was the exhilaration of
trying to keep up to date, and to anticipate the kinds of patients
who were being presented. My lectures lasted about fifteen to
twenty minutes.
At these noon meetings we would talk about other issues
relating to the presentations. If hepatitis was the disease under
discussion, there would be questions and an exchange of views on
diagnosis and management. We d then finish lunch and return to
work. I would be seeing clinic patients for the remainder of the
afternoon; and at the end of the working day, I would jump into my
car, a taxi, or a busdepending upon availabilityand go back to
Dhahran.
Hicke: Who headed these clinics that you remember? There were a lot of
different people, but...
Gelpi: Medical directors were appointed specifically for the districts.
Hicke: Can you give me the names of some people?
Gelpi: There was Dr. Armbruster, who was director of the Ras Tanura
clinic /infirmary when I arrived in Dhahran, and there was Dr. Les
McCoy, who left the medical service at DHC shortly after my
arrival, as the director of the Abqaiq clinic /infirmary. Dr.
Armbruster s major interest was occupational medicine; Dr.
McCoy s, internal medicineactually, he had been trained as an
internist. Of course the medical directors in the districts
changed- -not year by year, but there were several changes while I
was employed by Aramco.
Hicke: The other thing I wanted to ask was if you had any anecdotes that
are particularly memorable.
Gelpi: It s hard to remember the little things. There are a few which I
have already talked about: the consultative visit to see the ruler
of Qatar, the trip to Riyadh to take care of the minister of
agriculture and immediate members of the royal family, and the
109
other trip to Qatar involving investigation of the poisoning
epidemic.
More on the Journal Club
Hicke: Now the journal club. We talked about it before, but I wonder if
you could elaborate a bit more.
Gelpi: Our medical journal club developed along traditional lines, and
resembled those that have existed for generations of physicians
who have been involved in academic medicine, particularly in the
United States. A journal club consists of a group of physicians
who meet regularly, in an informal setting, to discuss the
contents of various medical journals reviewing articles of
particular interest, exchanging information and opinions about the
topics covered, and passing judgment on the quality of research
and the merits of its publication.
Another way to do thisperhaps more profitably for a small
group meeting at infrequent intervals is to have one of the
doctors pick a favorite topic and go into it in detail, using
articles from various journals to highlight a particular point he
or she wishes to convey to the group. To just go through a
journal by listing its table of contents and commenting briefly
about each article doesn t seem to be a useful educational tool.
Anyway, that s how we started our journal club meetings and
discussions built around specific topics. As far as I know, the
journal club established at DHC was still going long after I left.
I m pretty sure that when I made my last visit to Dhahran in 1981,
it was still going.
Hicke: Who was part of the club?
Gelpi: When we started there were three internists and a few interested
general practitioners (GPs). Then more people began to be
interested more GPs and doctors from the districts. The
pediatricians were not interested, because the topics were not
related to their training or experience in managing diseases of
childhood and infancy. And certainly, the surgical staff was not
particularly interested, for similar reasons. Some of the medical
directors in the districts became interested. So we began to have
quite a following. By the time I last visited, in 1981, the
medical department had expanded considerably, and I presume there
were many more internists and GPs in attendance.
110
Hicke: I think you said the journal club met monthly, as most journals
are published monthly. And who would set the agenda?
Gelpi: When I was there, I would set the agenda. Then when I left, it
was set by my successors.
Ill
VI RESIGNATION AND RETURN VISITS TO DHAHRAN
Leaving Aramco
Hicke: Tell me about your decision to leave.
Gelpi: There are several reasons for this decision. I left Dhahran on a
combined vacation/ sabbatical leave in the summer of 1967. I had
planned to work in the Department of Physiology at Stanford to
improve my laboratory skills in immunology, so that I could return
to Arabia and work on the immunology of ascaris infections. When
my family and I were in the United States, I began to consider the
long-term question of indefinite employment with Aramco versus the
option of putting down roots and pursuing a medical career in the
States. We were concerned about moving our children from a
protected educational environment in a family setting in Saudi
Arabia to schools in the U.S. or elsewhere. This meant a change
in primary education for our three children, from grades 1-9 in
Saudi Arabia, to high school in the U.S., Beirut, or Europe.
Finally, there was the question of whether medicine and health
care would continue to be as challenging for me in Saudi Arabia as
it had been when I arrived.
In the eight years I had been in Saudi Arabia, I was seeing a
rapid evolution of health care and a distinct change in the
spectrum of medical problems. We were seeing older patients with
Western diseases. Most of the exotic diseases were being
eliminated, or had been eliminated.
Hicke: Your successes were eliminating some of the challenges?
Gelpi: Yes. So I was considering all these questions during my
sabbatical year. In time, I decided that I would have to put down
roots sometime. So after eight years of living abroad, it was
time I settled in one place. Palo Alto, with its proximity to two
major university medical centers, seemed to be the ideal place to
112
begin a new career. I knew that the transition from grade school
to high school, no matter whether it began in Dhahran or the
States, would be traumatic. But in Dhahran, it would be worse,
because there would be geographical separation of our children
from us and from one another.
Hicke: Highschoolers have to go to boarding school, don t they?
Gelpi: Right. We had not reached this point with our children yet. In
any case, it looked like a new career in the States would not be
as exciting as that with Aramco. But there was another question:
whether or not I could spend more time on research while working
for Aramco, or would be consigned to less stimulating clinical
activities. So we decided to return, as a family, to the U.S. We
had found that there were many attractive features to life in the
Bay Area at the time. And perhaps the time had come to leave
Aramco and Saudi Arabia; and so we did.
Meanwhile, all of our personal effects had been put in storage
in Dhahran. And the prospect of moving them backeither to our
home in Dhahran, or a new home in Palo Alto--was not very
attractive. But this may have been the decisive consideration:
for in a sense, we had already moved out of Dhahran and Saudi
Arabia. To have returned meant unpacking over 100 boxes and a
move to another house in Dhahran. I felt an obligation to return
to Dhahran alone, leaving my family in a newly purchased home in
Palo Alto, in order to work until a replacement could be found for
me. Several months later, just short of 1969, I returned to the
States. I took a job with the Office of Economic Opportunities as
medical director of a new clinic for disadvantaged residents of
East Palo Alto. And of course, that is another story.
Hicke: Yes. Well, you did a lot.
Gelpi: But this was not the end of my relationship with Aramco. Because
in 1974 I began a series of five summer visits (1974-1978) to
continue some of the research I had begun earlier, and also to
provide vacation relief for physicians in internal medicine.
Medical Research in Dhahran. 1974-1978
Hicke: Tell me about this in more detail.
Gelpi: I was doing work on red cell genetic markers, which included
sickle cell trait, G6PD deficiency, blood groups, but was also
113
doing the reviews which would lead to an additional publication on
hepatitis in pregnancy.
Hicke: What was the time period on that?
Gelpi: I spent four to six weeks each summer in Dhahran for five
consecutive years. On occasion, I was able to employ a college
student, whose parents were living in Dhahran, to work with me
during the summer months. I would show them how to do the
laboratory work, and hire them on as laboratory assistants. This
slowed me down, but I think that it was worthwhile for the
students. And it eventually allowed me the extra time to devote
to clinical activities.
Hicke: Were these medical students?
Gelpi: Some were pre-med, some were interested in biomedical research,
and some were simply liberal arts majors.
Hicke: What resulted from these follow-up studies?
Gelpi: I completed the research, and this led to about a total of eight
to ten publications. I finished the investigations on red cell
genetic markers; and I finished the work on hepatitis complicating
pregnancy, for publication. That wound up my research activities
in Saudi Arabia. But I made a final visit in 1981, as a
substitute for another physician on leave.
Hicke: How long was that for?
Gelpi: I was in Dhahran for a month. My oldest son was working for
Aramco and living in Dhahran at the time; so we got to see each
other rather often.
Hicke: I wonder how he got interested in that! [laughs]
Gelpi: Well, that s another long story.
Hicke: All right. We ll stop here, and you can fill in any details when
we do the transcript. Thank you very much.
Transcribed by Lisa Vasquez
Final Typed by Shana Chen and Shannon Page
114
Regional Oral History Office University of California
The Bancroft Library Berkeley, California
Aramco Medical Department Oral History Project
Richard Handschin
PREVENTIVE MEDICINE AND MEDICAL DIRECTOR: 1958-1968
An Interview Conducted by
Carole Hicke
in 1996
Copyright C 1998 by The Regents of the University of California
Since 1954 the Regional Oral History Office has been interviewing leading
participants in or well-placed witnesses to major events in the development of
Northern California, the West, and the Nation. Oral history is a method of
collecting historical information through tape-recorded interviews between a
narrator with firsthand knowledge of historically significant events and a well-
informed interviewer, with the goal of preserving substantive additions to the
historical record. The tape recording is transcribed, lightly edited for
continuity and clarity, and reviewed by the interviewee. The corrected
manuscript is indexed, bound with photographs and illustrative materials, and
placed in The Bancroft Library at the University of California, Berkeley, and in
other research collections for scholarly use. Because it is primary material,
oral history is not intended to present the final, verified, or complete
narrative of events. It is a spoken account, offered by the interviewee in
response to questioning, and as such it is reflective, partisan, deeply involved,
and irreplaceable.
************************************
All uses of this manuscript are covered by a legal agreement between
The Regents of the University of .California and Richard Handschin
dated November 7, 1996. The manuscript is thereby made available
for research purposes. All literary rights in the manuscript,
including the right to publish, are reserved to The Bancroft Library
of the University of California, Berkeley. No part of the
manuscript may be quoted for publication without the written
permission of the Director of The Bancroft Library of the University
of California, Berkeley.
Requests for permission to quote for publication should be addressed
to the Regional Oral History Office, 486 Library, University of
California, Berkeley 94720, and should include identification of the
specific passages to be quoted, anticipated use of the passages, and
identification of the user. The legal agreement with Richard
Handschin requires that he be notified of the request and allowed
thirty days in which to respond.
It is recommended that this oral history be cited as follows:
Interview with Richard Handschin, an oral
history conducted in 1996 by Carole Hicke
in "Health and Disease in Saudi Arabia:
The Aramco Experience, 1940s- 1990s, "
Regional Oral History Office, The Bancroft
Library, University of California,
Berkeley, 1998.
Copy no.
Richard Handschin, November 1997,
115
TABLE OF CONTENTS- -Richard Handschin
CONTENTS 115
INTRODUCTION by A. P. Gelpi, M.D. 116
INTERVIEW HISTORY 117
BIOGRAPHICAL INFORMATION 118
I BACKGROUND 119
II JOINING ARAMCO 121
Interview and Hiring 121
Moving to Saudi Arabia 122
III EPIDEMIOLOGIST 124
Annual Malaria Survey 124
Other Staff Members and Personnel 124
Tuberculosis and Smallpox 125
Personnel in Preventive Medicine 126
IV CHIEF OF PREVENTIVE MEDICINE 128
Responsibilities 128
Maternal and Child Health 129
Health Education Program 132
Trachoma Research 134
Malaria Research 134
Occupational Health Program 135
Statistical Data on the Impact of the Preventive
Medicine Program 136
V MEDICAL DIRECTOR, 1964-1968 139
Outpatient Clinics: Statistics on Patients 139
Developing Public and Private Medical Services 141
Relationships with Company Management 142
Hiring and Educating Staff 144
Dr. Ivan Alio 146
Lecturing at the American University of Beirut 148
More Statistical Data About Changes 149
Crucial Leadership of Dr. Richard Daggy 150
More Data on Patient Care 154
Need for Nursing Staff 156
VI OVERVIEW: GOALS AND ACCOMPLISHMENTS 157
116
INTRODUCTION- -Richard Handschin, M.D.
Dr. Handschin obtained his M.D. degree at the University of
Rochester (Rochester, New York). His postgraduate training included a
residency in public health and a masters program at the School of Public
Health, University of California, Berkeley, where he obtained his M.P.H.
He joined Aramco s Medical Department in 1958, on the staff of the
Preventive Medicine Division. He was instrumental in developing the
division s strong health education, maternal-child health, and
occupational health programs. He did much to integrate preventive and
clinical services, both as head of Preventive Medicine, and subsequently
as medical director.
Handschin was a pioneer in developing Aramco s remarkable public
health outreach activities a model for corporations abroad, and for
developing countries. Because of special family needs, he retired early
from Aramco (1968) and went on to join Seattle, Washington s, Group
Health Cooperative (HMO) as research director. At the time of this
interview, he was ailing with chronic obstructive lung disease, from
which he died on April 25, 1997.
Armand P. Gelpi, M.D.
December 9, 1997
Sonoma, California
117
INTERVIEW HISTORY- -Richard Handschin
Richard Handschin served the Aramco Medical Department from 1958-
1968. Joining the company as epidemiologist, he was promoted the
following year to chief, Preventive Medicine. In 1964 he was appointed
medical director and remained in the position until he left Saudi Arabia
in 1968.
Born in 1918 in Champaign, Illinois, Handschin grew up there and
took his B.A. in Economics at the University of Illinois in 1942. He
served in the U.S. Army 1942-46, then took pre-med training in
California and obtained the M.D. from the University of Rochester in
1953. Four years later he received a degree in Public Health
Administration at the University of California. He was eminently
qualified to contribute to and later to direct the Aramco Medical
Department.
Handschin has the highest praise for the medical director who
hired him, Dr. Richard Daggy. Handschin speaks warmly of Daggy s
creative and persevering efforts in .preventive medicine on behalf of the
Saudis, whether company employees, their dependents, or villagers in the
Eastern Province.
The discussion in Handschin s oral history covers diseases treated
and research undertaken, other staff members and personnel, and
reporting procedures. His recollections are most valuable, however, for
the statistical data and careful notes he brought to the interview.
Using the outline sent by the interviewer, he describes his work in
detail, but most importantly, he offers statistics on the enormous
difference made by the work of the medical department, both in patient
care and in preventive medicine. His notes and data cover mainly the
years he was there--1958-1968--but in just these ten years, the progress
in public health was impressive.
Richard Handschin died April 25, 1997. He did not have the
opportunity to review the transcript of the oral history, which was
recorded on November 9, 1996, in Seattle, Washington. The transcript
was reviewed by the interviewer and by Dr. A. P. Gelpi.
Carole Hicke
Interviewer /Editor
June 11, 1997
Regional Oral History Office
University of California
Berkeley, California
118
Regional Oral History Office University of California
Room 486 The Bancroft Library Berkeley, California 94720
BIOGRAPHICAL INFORMATION
(Please write clearly. Use black ink.)
Your full name Richard Handschin
Date of birth October 17, 1918 Birthplace Champaign, IL
Father s full name Walter Fredrich Handschin
Occupation Professor of Agriculture Birthplace Calumetville, WI
Mother s full name Edith Knott Handschin
Occupation Teacher Birthplace Mt. Clare, IL
Your spouse Ula Steffani Handschin
Occupation Secretary Birthplace Maitland, CO
Your children Linda (46), David (43), Daniel (41), Lori (38), Rik (36)
Where did you grow up? Urbana, IL
Present community Bellevue, WA
Education U of IL (B.A. 1942); U. of Rochester (M.D. 1953);
D.C. Berkeley (M.P.H. 1957)
Occupation ( s ) Economic research & teaching (7 yrs.); preventive medicine
(7 yrs.); Medical Director (4 -yrs.); Research Director (15 yrs.)
Areas of expertise Analysis, planning and monitoring for health care
organizations (until 1983)
Other interests or activities The 19-mpmher Puget Sound Handschin clan
(including spouses) all live within 15 minutes. They are my major
interest.
Organizations in which you are active Silver Glen Cooperative a senior
housing cooperative where I, my wife and son live among 180 active
senior co-op members"!
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119
1 BACKGROUND
T f\
[The accompanving resume was furnished CURRICULUM VITAS
by Dr. Handschin] HICHARD HANDSCHN. M.D., M.P.H
P:;R5C K IAL DATA
?om: October 17, 1918, ChamDairn, Illinois
Married, ^ children, apes R throuch 18
and Uniformed Service;
19U" - Combat Medic, U.S. Army, Pacific Theater.
l^ i" to date - U.S. Public -lth Service Commissioned Reserve Corps.
AcMve Dutv, 1^5^-^. Inactive Reserve, 19^ to date. Current rrade: Surgeon.
19U? - 3.;. in Liberal 4rts (-Jcononics) , University of Illinois,
19U? I- 19^. - Graduate stuHent in Economics, University of Illinois, Urbana
- M.D., University of Rochester, ^ew York
.19^ . Rotating Intern, U.S.P.K.S. Hospital, Seattle, Washington
tll96 - Preventive Medicine Residency, Seattle-Kin? County Health Departmer.
19^ .! y P H. (Public Health Administration), University of California, Bj*-l<v
19?2 - Executive Proera-m in Business Administration, Columbia Universitv (< weeks)
19f3 - In-company Managerial Grid Seminar, Saudi Arabia (1 week
PUrLIC K.-1ALTH LX? ?~1~*:Z 2
. . Research Technician, California State Disability Insurance Proeram
Sacranento (2^ vears). Workload and cost estimation.
1952 (summer) - Research Technician, California State Department of Health
Nutrition Study, San Mateo, P months). Project coordination.
19^5-1956 - OverlaTOino anointments as Director of Communicable Disease
Control and Epidemiology (0 months) and District Health Officer (?1 months)
Seattle-Kine Co^ontv Health Department.
19 ^-l?^ - District Health Officer, Seattle-Kin? Countv Health Deoartment
(Q months). Suburban and rural area, ?0 nurses and sanitarians.
19 C B-1959 - Spidemioloeist, Arabian American Oil Company, Dhahran, Saudi
Arabia (20 months). Communicable disease investigation and control.
1959-196U - Chief, Preventive Medicine, Arabian American Oil Company,
Dhahran, Saudi Arabia (5 years). Direction of preventive i^ustrial and
community public health services for 12,000 employees and 60,000 dependents.
Administered 3 physicians and 80 other professional and technical personnel,
responsible for $700,000 annual total expenditures.
120
HEALTH SERVICES ADMINISTRATION EXPERIENCE
1Q64-19--8 - Medical Director, Arabian American Oil Company, Dhahran, Saudi
Arai-ia (4 yo^-s). Direction of comprehensive health care system serving
~l,GuO persons in 50,000 square mile area. 1*50,000 outpatient visits and
100,000 days of hospitalization annually in 5 hospitals totaling 450 beds
(3 of hospitals accredited by JCAH). 80 full-time physicians and dentists,
950 total health service employees. $14 million total annual expenditures.
(For further details see attached publication). Frequent advisory and ad
ministration contacts with other private and povernment health services in
Saudi Arabia and with World Health Organization.
1/6/69 - Research Director for Group Health Cooperative of Puget Sound
T"VCHI v :- A D ACAD-ffIC EXF ^I^C^
104? - Research 4ssi?tant in Economics, Universitv of Illinois, Urbana
(Q months).
T.9U< - Teaching Assistant in economics, University of Illinois, Urbana
(1 ser-.est=r). Taupht- 2 upoer class courses in Economics.
1Q55-195-? - Clinical Associate in Preventive Medicine, University of
Washington, Seattle (1 academic year). Tausht course in public health
aspects of ccrraur.i cable disease to student nurses.
lc^o_l^--7 _ Lecturer in Public Health and Lecturer in ipidemioloev, American
Universitv in Beirut, School of Public Health. Occasional lecture or
se-jLnar with public health or medical students.
1 = - Instructor, Aramco In-comoanv Managerial Grid Seminar. 3 week-lonp
c- -- v.tratod courses in advanced management techniques to ISO members of
>-. - arri uoT>er level Aramco ^an
preventive-Curative Sei"/ice? in Aramco" , TO. ?5- 7 0, Industry
ar.^ Tropical Health; VI, Inrtust^al Council r or Protncal Health, Harvard
"School of P-ablic Health, Boston, 1? 7.
OTH7R FRCFESSIOKAL O
Current Iv licensed to practice medicine in Washineton and California.
Certified in Public Health, American Board o^ Preventive Medicine - 19<
PRQg-:SSTCI-UL SOCIETY MiyBZ^SHIPS (M) OR FELLOWSHIPS (F)
American Public Health Assn. - Medical Care Section (F): American College
of Preventive Medicine (F); Royal Society of Tropical Medicine and Rveiene (F);
King County Medical Society (M), Washington State Medical Association (M);
American Medical Association (K); Zeta Chapter, Delta Omepa Honorary Public
Health Society (M); American School Health Association (M); American Society
of Tropical Medicine and Hygiene (M) ; Royal Society for Promotion of Health (M);
Association of Military Surgeons of the U.S. (M); American Association of
Public Health Physicians (M).
121
II JOINING ARAMCO
Interview and Hiring
[Date of Interview: November 7, 1996] ////
Hicke: We have your background and so I m going to start this morning
by asking how you happened to hear about Aramco and how you
first joined the company.
Handschin: Well, I saw an ad in the American Journal of Public Health for
an epidemiologist. I d always had an interest in Saudi Arabia,
dating way back to my exposure in National Geographic magazines
as a youngster. I had just completed training in public health
at the University of California, Berkeley, and I wrote and got
a job description of this job. It was an exceptionally and
precisely descriptive job description. I had just been
drafting some job descriptions for the Seattle-King County
Health Department, so I knew the difficulty of writing good job
descriptions .
Hicke: Yes, it is an art.
Handschin: And this was a superb description. And then I noted that it
had been drafted by R.H.D., which stood for Richard Daggy. If
someone were to be hired, they would work under him directly.
I thought, "Oh, that would be a wonderful opportunity."
Hicke: You had heard of him?
Handschin: No, never had heard of him. So, that s how I heard about it.
Hicke: And this was 1958?
Handschin: This was 1958. Then I made arrangements to travel--
122
Hicke: You sent an application; and were you interviewed for the job?
Handschin: Yes, I was interviewed, but I don t remember the details. Much
of what I have been able to recount now comes from notes that I
had used for speeches.
Hicke: Well, you don t think about those things for decades and so
it s hard to retrieve them.
Handschin: I was interviewed, but I don t recall the details. Then the
decision. We had four children at the time, the fourth child
was just about to arrive, and my wife had been enthusiastic but
she also had her fingers crossed. We were told at the tail-end
that there would be up to an eighteen-month separation. It
turned out that I left in April and my wife was able to join me
in October of 1958--so eighteen months shrunk to around six
months instead. But that was still far too long.
Hicke: Meanwhile she had the baby.
Handschin: Born on the third of March, and I left on 30 April.
Moving to Saudi Arabia
Hicke: What were your first impressions when you got off the plane?
Handschin: At that time there was not really a terminal. There was an
open quonset hut there when we got off the plane. The terminal
was, I believe, under construction at the time. Dick Daggy met
me. When he did, we were all standing underneath this quonset
hut with the wind blowing through, and he pointed out that the
chairman of the board was standing right next to us--and he was
dressed quite casually.
Hicke: Who was the chairman?
Handschin: I m blanking- -
Hicke : Okay .
Handschin: Anyway, Dick Daggy himself--! was surprisedwas wearing a
nice, button-down shirt. I thought, "Oh, this is a nice
mixture here of casualness and yet people who were savvy and on
board."
123
Then Dick arranged really an excellent orientation for
me. I visited not only all of the Aramco medical facilities,
but I spent a long time talking with the Dhahran people. I
also was introduced to the two local hospitals, and spent a
fair amount of time there. At those hospitals, they spent a
lot of time showing me around the two largest oases from which
populations many of the of the employees were derived and where
most of their families were living.
Hicke: That would be Qatif?
Handschin: That s right. And the Al-Hasa oasis near Hofuf. Some of the
people commuted back and forth to there, but some of them
actually only went home on weekends.
Then he gave me stacks of material that he had gathered- -
statistical data and reports for review. I think that it was
at the executive committee meetings of the Medical Department
where I got to learn a good deal of the inner functions of the
government. Everyone had excellent orientation.
124
III EPIDEMIOLOGIST, 1958-1959
Annual Malaria Survey
Hicke: Did they want you to learn any Arabic?
Handschin: I took some Arabic courses, but I never really became very
f luent--partly because I myself wasn t really involved directly
in patient care, although I did participate in the annual
malaria survey, in which we went into the villages and examined
all children of the village. All of the children would be
brought in, and we would examine them for the enlargement of
their spleen, which is an indication of infection with malaria.
I participated in that, and I learned enough Arabic to be
able to give instructions to the parent or the child while I
was examining them. Of those that had the enlarged spleens, we
took some blood specimens. In this manner we kept the tally of
what was going in the way of malaria. These young children,
who were completely susceptible, were kind of our sentinels to
tell us what was going on in the way of malaria transmission in
individual villages.
So, it was really a great experience. I was on cloud
nine. My children and my wife were not there; I was able to
put in many hours a day and many days of the week absorbing all
of this, and it was really quite exhilarating.
Other Staff Members and Personnel
Hicke:
Yes. Who else was there at the time that you recall meeting?
125
Handschin: At the time, Dr. Page was the medical director, Daggy was chief
of Preventive Medicine. I spent some considerable time with
Roger Nichols. Roger was the physician in charge of trachoma
research in Saudi Arabia. Over the years, I developed a very
close relationship with Roger.
Hicke: I talked to Elinor also when I was in Massachusetts.
Handschin: Oh, great, great family.
Those were people whom I had closest relationships with
initially at that time. Then I got started as an
epidemiologist there, which is what I d been hired for. The
first responsibilities I had were to review the disease-
reporting system that had been installed, to critique it and
analyze the data; to follow up on some data that we had,
looking for sources and methods of infection, and start to
draw, tentatively, some control mechanisms.
Tuberculosis and Smallpox
Hicke: Were there any particular diseases you were concentrating on?
Handschin: Malaria had been addressed fairly well, and I can comment on
that later. But one of the diseases that had not been well
addressed was tuberculosis. I tried to search out as much
information as I could on the occurrence of that. Early on we
started planning a 100-percent survey chest x-ray of all
employees, which had never been donepartly because of the
expense .
In doing that, I had the good fortune to work with the
physician here in Seattle-King County, who had been a leader in
mini-chest x-rays. They were small films that were only
seventy millimeters, twice the size of a thirty-five millimeter
film. And this man had interpreted over a million of these in
the Pacific Northwest and Alaska and was able to do it at a
high rate of speed and with a high degree of accuracy. Working
with himand I actually brought him out to Saudi Arabiawe
developed a program in which all persons were x-rayed. Close to
99 percent of our employees were x-rayed over a period of time,
and at the same time, smallpox vaccinated. So this was one of
the first major undertakings that we got off. We were able to
do that by the end of 59, and it worked out fairly well.
Hicke: It wasn t all in Dhahran?
126
Handschin: Oh no. We had to go to all of the major installations in order
to accomplish that.
Hicke: And did they bring in the people from the exploration camps?
Handschin: The people from the exploration camps rotate anyway, so we were
able to pick them up on their rotation. It was a considerable
effort, and loaded the bases, then, for really being able to
identify the infected persons and start up an excellent
program. Subsequently we started developing a manual on how to
continue to care for those had been identified, because they
were being cared for on an out-patient basis. Many of them
were able to work and, at the same time, be non-infectious by
having them on adequate antibiotic therapy.
Hicke: What about the families of the infected?
Handschin: The families of those people were also brought in for screening
to see if there d been propagation of the disease within the
household; and they were placed under care too.
Hicke: And also they were vaccinated for smallpox?
Handschin: That had been a separate program. We didn t have a program of
x-raying these people; we didn t x-ray them with the mini unit.
We brought them in individually and they were x-rayed with a
large film. I m not quite sure when we instituted a program
for routine smallpox vaccination, but I don t think it was at
that time, because they hadn t really started to work with the
major clinics on how to address some of the more significant
health problems particularly with dependents.
Personnel in Preventive Medicine
Hicke: If I interrupt you with a question that you re going to talk
about later on, you can just say so. But there are some things
that I don t want to pass up, like when you say, "We were doing
this." Who was the "we"? Was somebody working with you? Did
you have nurses or some other kind of staff?
Handschin: We ll talk about that later too, on how we organized. In large
measure, the people in Preventive Medicine were staff people
who did organizational work, developed programs, and assisted
in their implementation, but they didn t actually direct them--
with some exceptions. Initially, for example, I myself had a
highly capable Indian clerk--the best secretary I ve ever had.
127
I had an Indian clerk and the part-time services of a Lebanese
lab technician, who was quite fluent in Arabic. I used him if
and when I needed to.
At that time, there were about seventy people in
Preventive Medicine. That included sanitary engineers, a lot
of sanitary technicians, health education people in particular.
Then we had entomologists doing insect control and mosquito
control, assisting and advising the Ministry of Health on
control. All these things were going on. I never acted with
those people and was a member of their team, but they were
doing their thing and I was working predominantly at that time
in communicable disease.
Hicke: Was most of this set up by Doctor Daggy?
Handschin: Yes. Great guy. Did--?
Hicke: I did; I talked to him also.
Handschin: Oh, did you? Wonderful guy. How was his health at the time?
Hicke: He had had a stroke a year before I think, but he was doing
quite well.
Handschin: Is that right? Great admiration I have for that guy.
Hicke: Everybody seems to think he is a wonderful person.
Handschin: Yes, highly admirable man.
I didn t really see very many patients, although I asked
to see some patients as people who were being diagnosed with
particular diseases that I had interest in or that I knew very
little about. I asked the clinicians to give me a call and I d
come down and watch them as they examined or as they continued
to care for patients, kind of get a feel and ask questions as
to how the disease might have been propagated or acquired and
how it affected other people in the family and so forth. I had
very little contact, really, in the main, with patients at that
time.
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128
IV CHIEF OF PREVENTIVE MEDICINE, 1959- 196A
Responsibilities
Handschin: After I d been there--! forget--it was about fifteen months or
so, about a year and a half, Dick Daggy was suddenly advanced
to medical director, even though he was not a physician, but he
was a very skilled person in dealing with people, far more
skilled than I, in fact. So Dick advanced and he kind of
sucked me up with him. [laughter] I became the chief of
Preventive Medicine at that time, with the responsibility of
doing some overall planning and operating of an environmental
health program, being aware of, assisting, and directing the
sanitary engineering, insect and rodent control. We had a
small public health laboratory that did work related to disease
transmission.
Hicke: Such as?
Handschin: We did, for instance, some of the TB [tuberculosis] work. We
did the work on tuberculosis cultures and so forth. We did a
lot of work on malaria specimens. We did some work on samples
of milk and water specimens.
Hicke: Was this separate from the rest of the laboratory?
Handschin: Yes, it was. It was a separate establishment.
Dick had already recruited by that time an industrial
hygienist to work with toxic substances, of which there are a
number in an oil industry. And one of the most interesting and
fruitful interactions was with our health education unit. We
also invited a lot of staff services in planning and evaluating
programs that the Medical Department carried out in prevention.
In other words, many of these programs were carried out by the
129
clinicians and the nurses who were delivering care. We
developed programs that incorporated the preventive aspect, and
they became responsible for carrying those out. We had to do a
lot of training.
Hicke: Training the staff or the doctors?
Handschin: Training the people who were going to be delivering it, because
they had not been trained necessarily with an emphasis on
preventive aspects.
Hicke: I suppose the idea is you ve got the patient here, you should
take advantage of it.
Handschin: That s right. And many of them were having to come in from Al-
Hasa--more than forty miles away. So as long as they were
there, make the best of it.
Maternal and Child Health
Handschin: Much of that effort came from a maternal and child health
physician whom we recruited, Hazel Blair. She d previously
worked in Iran and Alaska. We also did recruit a public health
nurse consultant, who had experience also in Iran, Egypt, South
America, and China working with the World Health Organization
and other organizations. These people initiated an
investigation as to what could be the problems in maternal and
child health. It was obvious that there were lots of problems.
Hicke: Do I assume that if you have the names of these people, you
will pass them along?
Handschin: The names?
Hicke: Yes, like the public health consultant. In other words,
instead of me stopping to ask if you know the person s name,
you tell me the name.
Handschin: Oh, well, one of the names is Hazel Blair.
Hicke: Yes, she was a doctor.
Handschin: A doctor. And the nurse was Ms. Pitcherella. Pitcherspelled
even with a "T" I thinkand "ella." Pitcherella. "J" was her
initial. J. Pitcherella. Jeanette, actually, come to think of
it. We always called her "J"; she became our babysitter, and
130
Hicke:
Handschin:
Hicke:
Handschin:
Hicke:
Handschin:
she subsequently went to work in Alaska with an Eskimo group
after she left Aramco, and would come down here and visit us.
I saw her in about 93. Yes, in 93, I went to back to my
University of Rochester for the fortieth-year reunion of my
class. I graduated in 53, went back in 93. We made a
special trip to go down and visit her in New Jersey and boy, we
were glad to do so. She was in fair health then, but two
months later she was dead.
These were really skilled people. They used English-
speaking Saudi girls in addition. We had a few senior staff
Saudis, who were upper echelon people, who lived in senior
staff camp amongst Americans and whose daughters attended
senior staff schools and were fluent in both English and
Arabic. We used several of those girls to assist in these
investigative efforts.
They went along when you would go out to the villages, is that
what you re talking about?
Yes, yes. They assisted us with visits to homes, talking with
parents in particular, revealing the foodstuffs and their
availability; the methods of growing those foodstuffs; how they
were marketed; how foods were prepared; what foods were
acceptable and what foods weren t; and actual nutritional
analysis of some of those foods.
You went into all that?
This was the basis that took some time to discover, because
malnutrition was a major problem. It took some time to
discover what was going on, what were the resources to combat
it, and what were the cultural views about the feeding of
children. There was a malnutrition problem principally in the
first few years of life
I have to interrupt you again.
Aramco dependents?
Are we talking now mainly about
Yes we are, yes we are. We talked about how conception
occurred, what people felt about pregnancy, how they acted
during pregnancy, about delivery, and about childcare. There
was actually a lot of frank malnutrition, including
quashiorkor, a classical disease of protein deficiency in which
female infants were never breast-fed. The male infant wasn t
always taken off the breast when the second child or the
subsequent child was born, particularly if the second child was
a girl. And the woman might not increase her food intake.
These youngsters suffered frank malnutrition as a result.
131
Hicke: I ve seen some slides of a couple of those kids. Awful!
Handschin: One thing that came from these studies was the real cause of
the problem. Adequate amounts of suitable foods were available
to most families; there an was adequate amount of protein,
either from meat or fish or from cheeses or from lentils. But
it was not considered appropriate to feed these to children
until they were three or four years old. And so as a result,
we found later even if you encouraged people to use these foods
and feed a child who was six months, ten, twelve, fifteen
months, feed these foods, if the child once rejected it, the
mother would say, "I told you so!" And so it took an awful lot
of convincing the people that this was a desirable thing to
feed these infants foods, particularly protein foods
sufficiently. It was actually malnutrition in the midst of
plenty.
Hicke: That s amazing.
Handschin: And it was all based upon cultural beliefs that these were not
good foods for children.
II
Handschin: Although actual frank starvation was probably pretty much--
Hicke: Are you saying "frank"?
Handschin: Yes, meaning true. The problem is that you can t sometimes
tell the difference between starvation per se or malnutrition.
Why did some people die? It was usually malnutrition with
superimposed diarrhea on top of it. They were really very
vulnerable to any infection because of the malnutrition,
including pneumonia. It was an admixture. Incidentally, it s
not so unique to Saudi Arabia. I find that I had two uncles in
1875 who probably died of malnutrition in Wisconsinpeople
trying to make a living on cut-over land that was inappropriate
for farming purposes at the time, and unable to keep their kids
healthy. As one uncle said, they probably really starved to
death. He said that they were just were skin and bones when
they were sick. It s exactly what was happening in Saudi
Arabia.
Hicke: Except that they had the food available in Saudi Arabia- -didn t
know how to get it to the kids.
Handschin: What was lacking was suitable child-rearing techniques.
Hicke: Yes. Interesting. That s an amazing story.
132
Handschin: There was a really massive gathering of data by these people,
then some testing of hypotheses, and then the beginning of
training of some nurses and some physicians to start to teach
what should be given to people whom they were seeing now as
patients, what should be done.
Several different approaches were tried, and they didn t
all work. Then ultimately, a fairly well-designed program was
beginning to gel during my days, and it was mainly addressing
malnutrition more than anything else. That was the basic thing
that was causing the highest infant mortality rate.
Hicke: Is this the maternal and child care program we re talking
about?
Handschin: This is the maternal and child health program.
Hicke: That is interesting, because I would have thought that just
from the name of it that it was teaching mothers how to take
care of their babies and that sort of thing. But it was
considerably more than that.
Handschin: Well, this s_ taking care of their babies.
Hicke: Well, yes, that s truebut not just changing diapers and so
forth.
Health Education Program
Handschin: Associated with that, I d like to say some things about the
health education program.
Hicke: Yes, I wanted to ask you about that.
Handschin: It was principally under the direction of Mitchell Owens, a
very fine health educator who devised most of this. He did a
whole variety of things; I can t remember all the things he
did, but let me cite some of them. First of all, hewith the
assistance of crews that were brought from the U.S. --did a
series of color movies on trachoma, on malaria, on community
sanitation, on personal hygiene. These also were shown on
television. They had the television station there that had
allegedly as many as three hundred thousand viewers, but I
don t believe that. But there were an amazing number of people
who did have access to television.
133
These were also shown in the public schools. Aramco had
a program of building public schools, and in the end I think
they built seventy public schools. In those public schools,
and in others, we had a program in which our health education
people went into those schools. They were fluent in Arabic.
They were Middle Eastern, predominantly Jordanian and Lebanese.
They carried these movies into the schools; they carried a
great number of pamphlets into the schools. Later, September
of 1960, into girls schoolsno girls schools before that.
We even developed a curriculum for the teachers--to
assist the teachers in this, including books that were
specially designed and produced addressing the problems of
health in Saudi Arabia. These books were then produced and
given to the students at a particular level, I can t remember
which. I think it was the equivalent of the sixth grade when
the youngsters would leave that elementary school. They could
keep this and take it home. It was a nicely bound, hardcover
book with illustrations, and with illustrations that were
specifically designed to be compatible with Saudi lifestyles in
a just beautifully done pie-ce of work.
Hicke: Was that done at Aramco?
Handschin: It was done by Mitchell Owens and his people. The graphics and
so forth were farmed out. It was very well done. In addition
then, they conducted family health classes. These were done
out in the villages. There they used some of the Saudi girls
who were from senior staff families. There was a weekly TV
program on health; I think it was about fifteen minutes. It
was pretty popular, with an opportunity to write inthat was
before the days of call in--to suggest questions or what you
didn t understand and so forth.
Hicke: This was Mitchell again?
Handschin: This was all Mitchell, but he had a lot of skillful people- -
including a number of American wives who had particular skills,
some of whom had worked in television and so forth. So they
were very useful too. Actually, the attempt was to really
develop a willingness among Saudis to both accept and then to
maintain health care, to utilize it, to recognize when they
should utilize it, to understand that health care also involved
washing your hands and a variety of lifestyle changes, and try
to get them to maintain the things they learned from health
care.
Hicke: Let me interrupt again. Change is difficult for people.
134
Handschin: Oh yes.
Hicke: How did they manage to persuade these people to change their
lifestyle?
Handschin: Well, we ll talk about that some later on, when I discuss
directing the Medical Department; we ll talk about how they had
to do that for women who were coming in.
Hicke: Okay. That would be fine.
Trachoma Research
Handschin: There are a couple of other things as well while I was an
epidemiologist. You had asked something about description of
research carried out while I was the chief of Preventive
Medicine. I might just take this time to talk about the
trachoma research, which regularly was not directly under my
purview as I was chief of Preventive Medicine; but subsequently
when I was medical director, Roger reported to me.
Aramco donated over a million dollars for trachoma
research, which was started in 1954 under Dr. Snyder--John
Snyder, J.C. Snyder--who was dean of the Harvard School of
Public Health. Much of the research was carried on in Saudi
Arabia, but elsewhere too; they traveled to observe trachoma
elsewhere. And quite a bit of work was done in Boston in the
laboratory there for over ten years, including isolating the
organism; developing tests to type the organism and identify
it; and some attempt at developing a vaccine, which did not
prove successful. Ninety-five percent of Saudi Arab employees
showed evidence that they d been infected with trachoma, and
although many recovered without major difficulties, it was at
that time the leading cause of blindness in the world. So
there was considerable effort in trying to do something about
it.
Malaria Research
Handschin: Another aspect of research that was going on was the malaria
survey, which I indicated was done annually in a variety of
different villages; and then I already mentioned we examined
all the children in the village, particularly those who were
135
under two or three years of age, who were likely to be able to
tell us [through the examination] what has happened in the last
year or two by the fact of whether they were infected or not.
We shared all this information with the Ministry of Health. We
did a lot of research work on the resistance of mosquitoes to
insecticides. And as a matter of fact, at that time there was
a resistance developing, and we assisted the Ministry in
identifying the one particular insecticide that was no longer
being satisfactory in suppressing the mosquitoes, and assisted
in choosing some others. Research was being applied almost
immediately in continuation of malaria control. Malaria was
not really eradicated, but it was very effectively being
controlled during this particular period in time. I ll talk a
little more about that when I talk about the impact of
preventive medicine on overpopulation.
Occupational Health Program
Handschin: We did at that time also hire an occupational health physician.
He principally worked along with an industrial hygienist on
some of the noncommunicable disease exposures that our people
had. Heat exposure was a big problem in Saudi Arabia.
Hicke: I can believe it.
Handschin: Particularly, for example, working offshore. We had drilling
rigs that were located offshore. The humidity was tremendous.
Those people worked forty- five minutes, and then they had a
fifteen minute break in a cooler atmosphere. Changes in this
patternwhen breaks should be given, and how frequently- -were
developed on the basis of some recommendations that came from
our occupational health physician.
Hicke: Do you recall his name?
Handschin: Paul Mossman.
We also had problems on noise exposure, because a lot of
activities are in noisy refineries. So we had a hearing
conservation program, in which people were tested in certain
strategic areas where it was likely that they would have
diminution of hearing. Altering the work situation to provide
baffles for sound or to obtain a variety of ways of
ameliorating the risk was done through this program.
136
We had a lot of problems with back injuries, so we were
trying to teach people how to lift and also how to organize
work so that the back injuries were not likely to become a
consequence. So our occupational health people had a lot of
work to address, and it was one of the areas in which I gave
very little supervision; these people were professionals in
their own right, and mostly what they needed from me was
assistance in equipment or assistance in arranging contacts and
so forth. They were very good independent workers.
Statistical Data on the Impact of the Preventive Medicine
Program
Handschin: You asked on the outline at the end of the chief of Preventive
Medicine section something about the impact of preventive
medicine programs on the local population. Let me cite some
data that I gathered out of looking at some notes.
Hicke: Oh, that would be great.
Handschin: Formerly, there had been thousands of malaria cases treated
annually. For example, in 1947 there were 12,000 visits to
clinics by employees for malariaand a total of 30,000 visits
altogetherbut 12,000 of them were among the employees.
Hicke: That s impressive.
Handschin: Ninety to ninety-five percent of children had malaria. One
quarter of the employees had at least one attack a year. Now
by 1963, there were less than a dozen cases of malaria acquired
in the Eastern Province among our employees. That s a marked
difference: from one quarter of the employees having at least
attack a year down to a dozen cases a year, which had been
acquired in the Eastern Province.
We had a program, starting in 1958, in which Saudi women
were selectively interviewed as they were coming through clinic
at the time of Ramadan. Ramadan, the fast and feast month of
the year, is well remembered by people, so that they always
knew events as what had happened before or after the last
Ramadan. So at Ramadan each year, we interviewed women as to:
"Have you given birth to a child since Ramadan?" "Is that
child surviving?" "When did that child die?" From this type
of interviewingit s very simple, two or three or four
questions is all it took- -we were able to find out that in 1958
one out of four children died within the first year of life.
137
From one Ramadan to the next, one of out four children in
their first year of life died: 250 out of 1,000. That was
1958. By 1966, which was only eight years later, it was down
to 30 out of 1,000 instead of 250 out of 1,000. At that time,
the infant death rate in the U.S., death in the first year of
life, was twenty-one; and by 1966 in this group of Saudi women
who had been exposed, we were down to thirty.
Hicke: Are you going to tell me what that s attributable to?
Handschin: It was attributable to the MCH [maternal and child health]
program that Hazel Blair headed up.
Hicke: Mainly overcoming that malnutrition?
Handschin: Malnutrition and other aspects of child care too.
During the seven-year period from 1960 to 1967, there
were no employee deaths due to tuberculosis, pneumonia,
malaria, smallpox, infectious hepatitis, typhoid, or any
viruses. These were all diseases which in the early days were
causes of death. And that was a seven-year period in which
among those one, two, three, four, five, six, seven diseases
which had been common causes of death in the forties and
fifties among our employees. There were none in that period.
Hicke: What a story!
Handschin: In the 1940-50 period, all of these were prominent causes of
death. Comparing 1960-67 with the 1940-49 period, there was a
98 percent reduction in the communicable disease deaths, and a
53 percent reduction in accidental death. I mean, these are
rates per thousand. Part of this related to other things, such
as company housing, which was not just housing for bachelors or
in bachelor-type quarters, but also in town sites adjacent to
the major installations. These were little villages which the
company built. All of these had running water in each house;
running water is a great godsend. Soap and water can do a
great deal in controlling disease. It doesn t even have to be
high-quality water; it can be just water, because it gets used.
All these had excellent sewage disposal; they had fly control;
they had vermin control. All of these were developed by our
preventive medicine group, who worked with those town sites to
make sure that they had-- Well, that gives you some idea of
the impact that was going on. Maybe I ll have some more later.
Hicke: When I talked to Bill Taylor and I told him that I was going to
be interviewing you, he said during your time there was a
138
spectacular change in public health. You just indicated that,
It really was an incredible improvement.
Handschin: Yes, it certainly was. Well, let s go onward.
139
V MEDICAL DIRECTOR, 1964-1968
Outpatient Clinics: Statistics on Patients
Hicke: In 1964, you became medical director.
Handschin: [reading outline] "Developing procedures for outpatient
clinics."
Hicke: I understand that was one of the things that you did.
Handschin: A large part of this was related to maternal and child health.
Let me give you some figures, then. During that time when I
became medical director, we were caring for about 69,000
people. Thirteen thousand of them were employees. That
constituted 19 percent of our people for whom we were
responsible. Wives accounted for an additional 16 percent.
Children accounted for 59 percent of the people we were
responsible for. And the Saudi Arab parents, for whom we
became responsible, accounted for 6 percent of the people that
we had to care for.
Hicke: Employees parents?
Handschin: Saudi Arab employees parents.
About 92 percent of our population that we were covering
were Saudi Arabs, 6 percent were American at that time, and 2
percent were of every other nationality. That 2 percent was
low because they didn t have their families; they weren t
permitted and we didn t care for them. In 1968, which was
towards the end of my tenure, one out of thirteen people in
Aramco worked in the Medical Department.
Hicke: One out of thirteen?
140
Handschin: That would be about 7 percent, something like that and we used
6 percent of the company s total operating cost. And about 12
percent of our Medical Department costs were for prevention:
about a million dollars a year was being spent on prevention at
that time.
The principal cause of severe, serious illness in
children was the malnutrition-diarrhea complex. It was the
biggest single health problem. And it was through the
developed procedures that Hazel Blair and Jeanette Pitcherella
spent so much time writing procedures for outpatient clinics.
They d plan these preventive aspects, then they d teach them to
the people who were going to utilize the techniques. There
were other things that were being done in addition to
preventing malnutrition. For instance, we had problems with
tetanus in the newbornchildren being born and the umbilical
cord wasn t handled properly. Most of these people were being
delivered by midwives in the village. But they weren t really
midwives; they weren t trained midwives.
Hicke: Just an older woman?
Handschin: They were casual cronies who did this. And we had a lot of
trouble with tetanus in younger children. So one program for
the prevention of this was to immunize women, even before they
became pregnant, you see. And their antibodies went through
the placenta and protected the child. We also developed
because of considerable need a program of giving BCG, which is
a tuberculosis vaccine, to newborn infants.
In the clinics we developed some day-care units in the
clinic, right adjacent to where the curative medicine was being
practiced. The mother could be sent by the doctor or nurse to
stay in that unit for eight hours to receive education that
seemed to be appropriate for her particular problem. For
instance, the mothers would prepare the food for the child
there, and they would feed the child under the tutelage of the
nurse. And not only once, but repetitively, so that in an
eight-hour time period, they would feed the child maybe three
or four times. Each time, that activity would be critiqued. A
lot of this was group instruction. There d be ten or twelve or
fifteen mothers there in that particular room, and there "d be
an interaction in that group maybe not with neighbors, but
with people they could talk quite freely to because they were
the same clans.
141
Handschin: During those all-day sessions they also got new information. I
have emphasized food preparation, but there was also emphasis
on skin care- -because you had a lot of problems with skin
infections also upon the whole care of an ill child: how to
respond to minor ones and those that required more care.
Hicke: When to see the doctor.
Handschin: Yes, that s right.
Hicke: That s the hard one.
Handschin: But in our case it often was when to see the nurse, too. We
trained nurses for screening. We had no Saudi Arab females
available. We used predominantly Middle Eastern female nurses,
Indians doing the more clinical, the more routine aspects of
care. But most of these people active in the actual on-the-job
training were Palestinian, Jordanian, some Egyptian. We had an
English gal who spoke Arabic pretty well too. These were all
trained in Aramco by our MCH nurse and our MCH physician, which
was really a major thing to do that.
Developing Public and Private Medical Services
Handschin: Another aspect that we really had to do as a medical department
was assisting in the development of public and private medical
services in Aramco--non-Aramco services and to some extent
allocating some medical service to the general public where it
wasn t possible for the public to get that kind of service. We
helped establish the first hospital in al-Khobar--a town of
about 35,000. I m suddenly blanking on the name of it. It was
a private hospital. Al-Sharq was the second hospital in this
same area. But when this first one was established, we
provided initially 90 percent of their patients. They were
Saudi employees and Saudi dependents, principally Saudi
dependents, I should say. They had on their staff twelve well-
trained, non-American physicians, some of whom had been trained
in America. It was a large, well-run hospital. They had, for
instance, a center for preemies that was the equivalent of what
was available in many parts of America.
Hicke: That s wonderful.
Handschin: We had assisted in the establishment of the second hospital;
about 85 percent of its patients were Aramco.
142
Hicke: These are contract hospitals, right?
Handschin: These are the contract hospitals. In both of these hospitals,
Aramco supervised and audited their care. We had Dick Perrine,
who was in charge of this, the liaison physician. Almost every
aspect of their medical and nursing care was audited and
reviewed to see how it was going. The general public was free
to use these; initially, of course, it was only the more
affluent ones and expatriate personnel. There were many
expatriates in the area who were attracted because of the
opportunity for economic endeavor supporting Aramco, selling
things to Aramco.
Hicke: Are you talking about American expatriates or all kinds?
Handschin: Not necessarily. There were Indians, English, Germans, French,
Americans and so forth, a great variety. These hospitals
provided a resource for that group of people too, including
those who had brought their families along.
In addition, between 1963 and 1966, a four-year period of
time there, we paid about a $135,000 a year to a team of
consultants from the World Health Organization to assist the
government in developing the health services for about 360,000
people in the population who were not Aramco employees and who
needed care--in particular, to work on one hospital which had
been sitting idle for five years unutilized, and to get that
going; and they did. They were able to get that hospital open;
and although the care was far from what we would like, it was
there.
In the year before we started that program with WHO
advising and expediting, the year before that we provided $1.1
million in care to the general public in 62. In 66, four or
five years later, $400,000 only--a significant reduction. Of
course, we had expended $400,000 providing the advisory
assistance for that. Later, Aramco expended at least $700,000
in total to the World Health Organization. I have no data, but
I know that there was continued progress.
Relationships with Company Management
Handschin: You want some things about my relationship with company
officers and reporting procedures. I reported as medical
director to the vice president of Industrial Relations.
Sometimes they had a slightly different title than that, but
143
basically that was it. In some instances, I used to relieve
Dick Daggy when he was on long vacation. I served under several
different vice presidents of Industrial Relations, including
two who ultimately became presidents of the company; so they
were quality people.
Hicke: Who were some of these people?
Handschin: [Bob] Brougham was one, and Listen Hills another. I guess that
what had happened was that Dick Daggy had established a
remarkably good relationship with company managementbecause I
just fell into it and found that our relationship was always
one of cordiality. I was at ease. I was usually able to get
what I wanted. I found that the transmission of information
upward to them about our needs, our successes, or our failures
was really an enjoyable activity. I enjoyed that aspect of my
work more than maybe many others. I also enjoyed defending the
department against some budget cuts, and I think I was largely
successful in those interactions.
For instance, I felt that I was given a lot of respect,
and I had a lot of respect for these people. All that had been
prepared by the type of interaction that Dick Daggy had
established. I just lucked out.
Hicke: Well, I m sure you had some input also. That sounds like a
very good working relationship and one of the reasons you were
able to do so much for them.
Handschin: And there was a keen understanding of what we were doing in the
way of preventive care at the highest level, including Tom
Barger, who was at that time the chief executive officer.
Barger had a thorough understanding. Barger would come down
and go with people like Dick Perrine and me. I remember one
time the three of us went to visit because he was interested in
these private hospitals, the contract hospitals. He came down
and said, "Let s go visit." It was really unannounced. He
said, "I just thought of it today," and very informally came
down. Perrine was there, and the three of us hopped into Dick
Perrine s little Volkswagen.
And Barger was a tall man too. We had called ahead to
tell them that we were coming. The first hospital we were
visiting was headed by a Palestinian, who had spent a lot of
time in the U.S., incidentally. He was a physician. And he
was very surprised to see the chief executive officer crawl out
of the back end of a Volkswagen! [laughs]
Hicke:
Handschin:
Hicke:
Handschin:
The two of you unfolding yourselves!
It illustrates how things got done.
That s a good anecdote.
It was really a very egalitarian community; people had very
little pretense. Barger especially was a very admirable man,
very admirable.
I
Yes, I understand from what I ve heard about him that he
certainly was responsible for much of the interest in the Saudi
culture.
He was. He was a student of the Arab people and the Arab
culture, and an appreciator of that. As a result, he was
admired by the Arabs, who recognized the empathy he had.
Hiring and Educating Staff
Handschin: [reading] "Talk about recruiting and hiring." I did very
little of this, actually. Largely the recruiting and the
hiring of staff were done by people directly under me. They
had the savvy to know what kind of people they wanted. They
reviewed them with me, but I did very little. When I was chief
of Preventive Medicine I did do some hiring. I helped hire
Hazel Blair and Jeanette Pitcherella. I hired the
epidemiologist, Ivan Alio. I recruited him directly. I was
responsible for the recruitment of Gordon Flora. I don t think
I ve ever met him. But I was working with some people from
Booze, Allen, Hamilton who had provided a variety of names, and
I recognized that this man probably had the most suitable
background among the many candidates. But I ve never met him,
that I recall. I say that, maybe incorrectly, because I find
that I ve often forgotten people whom I ve actually met.
[reading outline] Let s see what else I have. I m about
ready to move to the second page here. "Ongoing education of
staff." Well, one thing, of course, I ve already described
something about the re-education we had to do among clinical
people who were predominantly curative in their viewpoint.
That involved a lot of education, of "Hey, it s really
important that you report communicable disease." But it s also
much more elaborate than such things as that. It s "In your
preventive practices, you are going to be held responsible."
Hicke: This was a new approach, right?
145
Handschin: That was a new approach. It was not accepted by everyone.
There was quite a difficulty. We didn t win all the battles,
but we were most successful probably in the area of
tuberculosis control, where we had a tuberculosis control
physician who really believed in prevention. Another area was
the whole area of maternal and child health. We did pretty
well there, in the long run. Then, ongoing education of staff:
we had a whole program at Aramco--! forget its titleit was
management and professional development, in which we had a plan
for every key person as to what they might benefit from in the
way of additional training, and when it might be. That
training could be on the job training, for instance, to rotate
them through different assignments. I was medical directoras
vacation relief --for two months or two and a half months, I
would be assigned to Ras Tanura and would run the Ras Tanura
medical center or Abqaiq.
So similarly, we did this for everybody. This could be
on the job training or it could be educational leave, or it
could be sending somebody to a year at school, which we did,
for a master s in public health. David Weeks, who became chief
of Preventive Medicinewe sent him off for a year of public
health training at Harvard. I was sent for training in
executive management at Columbia University s campus at Arden
House in urban New York six weeks of rubbing shoulders with
executives from IBM and a variety of other people. There was a
whole program, and this was reviewed annually, not only with
the personnel department to make sure that you had this but
you had to review it also with your boss, all the key people
underneath you, and so it went. Then if we felt that people
were weak at particular management skills, then we gave them a
short course that might be available in the field or actually
have them spend some time substituting for somebody. So you
got an idea of what it was: "Hey, you re just objecting to all
this; somebody is going to be gone a month, why don t you fill
in?"
Hicke: See how it looks from the other side.
Handschin: So, I spent a lot of time on some of these programs, assisting
and advising on how surgeons should be upgraded, the new Saudi
surgeons we had brought on.
You asked about Tapline outposts. We didn t figure that
much with Tapline. We backed them up occasionally on medical
care. They had pretty much their own outlet. We brought some
of their medical people down and gave them some indoctrination
in some of the things that we had learned, but they were people
146
that had been trained at American University in Beirut largely,
They were pretty capable on their own.
Dr. Ivan Alio
Hicke:
Handschin:
How about the U.S. military?
with them?
Did you have much interaction
Hicke:
Handschin:
I didn t have any, although I recruited my successor as
epidemiologist, Ivan Alio, there. Most interesting guy. He
was a Macedonian, and when part of Macedonia was taken over by
Greece, his father moved to Sophia. And so he, who had spoken
Macedonian as a child, grew up in Sophia, Bulgaria, spoke
Bulgarian. But he took French too, because his father had been
educated in a French medical school; so he took French and
ultimately he was going to go off to France. Just about that
time, the war came and Bulgaria was on the other side; so he
went off to Germany and went to medical school in Germany and
learned German.
So a Greek-Macedonian-Bulgarian-French-German-speaking
Ivan went through medical school.
And eventually he must have learned English.
Well, not yet.
Then he went back to Bulgaria. But he didn t like it; it
was after the war was over and he didn t like it. He made
plans to get out, and he was able to go on leave to Prague, and
he got into Prague just as it was falling to the Russians after
the war. He skipped out of there in a hurry and he got to
Italy.
In Italy he was in a refugee camp, and he served in this
refugee camp as a physician. He started to learn Italian,
quite a bit of Italian. He was there for a long period of
time, and he wanted to get to America. So he started doing
research in what kind of things could he become skilled in to
emigrate . He found out the list of things that were in demand
in the Americas, and one of them was a skill in, as I recall,
textiles--re-dyeing of textiles and production of textile
products. So he did research in Italian in the local libraries
that were available on this, and he was able to pass the test
proving that he would be competent to assist in the development
of some kind of textiles. And as a result, he had an
147
opportunity to go to either Peru or Bolivia. I forget which.
I think it was Peru, but I m not certain. When he found that
out, he started studying Spanish. He said that he got off the
plane in Peru, Ecuador, Bolivia--! forget whichand he said by
the first night he had a date with a girl, and he could carry
on a conversation in Spanish that was passable.
Subsequently he migrated to Venezuela, where he served
under a world-famous malariologist. He trained under and
served under this fellow on malaria control in the upper
reaches of Venezuela, a really primitive area. But his mentor
told him if he really wanted to get ahead, then he ought to
train in the United States and encouraged him to make an
application to the school that he had attended: Johns Hopkins
[University]. And lo and behold, he was accepted at Hopkins,
even though he wasn t fluent yet in English. But he had
started.
He was accepted and went to Johns Hopkins and learned
English. He met a girl there who became his wife. She was
employed at Hopkins, in clerical or secretarial, and she did a
lot of tutoring. He went through and got a Master of Public
Health at Hopkins.
Hicke: What an amazing story!
Handschin: Then, in order to expedite his American citizenship, he joined
the [U.S.] Army and served in Korea, where he was an advisor in
preventive medicine to the Korean armed forces. And he learned
a good deal of Korean! He just had this innate facility for
learning a language very rapidly. I think he was in Korea two
or three years, then came back and was about ready to be
discharged when he saw our ad for an epidemiologist. I
interviewed him at Fort Leonard Wood in Missouri on a vacation.
So that was one person that I was actually responsible for
recruiting. I brought him out to Saudi Arabia. He was an avid
student of Arabic, and it wasn t long before he was quite
capable in Arabic.
He was also in the military reserve; the military was
using him to provide information about health conditions in
Saudi Arabia. He did an enormous amount of traveling in Saudi
Arabia for the benefit of Aramco and for the benefit of the
American military, describing living conditions and health
conditions, occurrence of disease, and availability of medical
f acilities describing the health infrastructure of the country
for us and for the American military. So that s the only
instance I can talk of in which I know of direct interaction
with the military.
148
Hicke: Oh, but that was a wonderful little history of Dr. Alio!
Handschin: Oh, he was a very interesting guy. He had some rough edges,
but he was a guy who was most intriguing to listen to. Later
he went back and visited in his old country, and brought out a
priceless icon from Bulgaria that had been in his family for
several generations. His mother was still there. But he had
covered his tracks well. He had arranged that everything was
in order as he left there, and he left nobody dangling up in
the air.
Hicke: That was wonderful.
I*
Hicke: You were just going to tell me what happened to him later.
Handschin: After he left Aramco Ivan Alio became medical director for the
Peace Corps, a position which he held through at least six or
eight years. He was the medical director for the Peace Corps
and was, once again, active traveling. He was a most
inquisitive and acquisitive guy: he wanted to know things and
facts.
Hicke: I m glad to hear so much about him.
Lecturing at the American University of Beirut
Handschin: You ask about lectures at AUB. Actually, I made very few.
Principally they consisted of descriptions of Aramco s
programs; descriptions of the health conditions observed in
Saudi Arabia; descriptions of our nurses, many of whom had been
trained at AUB; sanitary technicians, how those people were
being used in Saudi Arabia; what they had learned at AUB that
was of help and things they had to learn additionally that
hadn t been provided at AUB; and how physicianswe used an
awful lot of American University of Beirut physicianshow they
had been utilized and how they had opportunities for
advancement and so forth. So those lectures at AUB were
principally in the School of Public Health, although I think I
gave one or two to the School of Medicine. But I was not on
the School of Medicine Faculty; I was on as a lecturer in the
School of Public Health.
149
More Statistical Data About Changes
Handschin:
Hicke:
Handschin:
Hicke:
Handschin:
Hicke:
Handschin:
Hicke :
Handschin:
[reading] "Something about changes that I observed during my
time in Arabia. "
Enormous, for one thing- -
Yes.
--the changes that you effected while you were there,
other things.
But--
In 1952, six years before my time, there were three non-Aramco
physicians in the Eastern Province, at a population then
probably close to 300,000. In 1967, fifteen years later, there
were ninety-two employed by the Saudi Arab government. In
fifteen years they d gone from three to ninety-two. By that
time, they were located in twenty-four different towns, and
there were at least nine different specialties that were
represented among those things.
Nearly all of those Saudi Arab government physicians also
were practicing part-time as private physicians. That s what
attracted them: most of their income was in the private
practice. So half-time, half-time. Or, a full-time position
with the government- -which was about a six-hour day--and then
six hours of practice in the evening in their private clinic.
Some of these were at the contract hospitals, right?
Some--well, no. We ll go on to those.
Okay, go ahead.
Then in addition to those ninety-two who were employed by the
government, there were sixty who were solely in private
practice. They were located in only six towns, the larger
towns, including al-Khobar, as an example. There were also at
least nine specialities represented. So you add these up--
you re talking about the non-Aramco physicians: 152, fifteen
years later from the time there were only three.
And if you add in the Aramco physicians, there was a
total of sixty-five doctors per thousand in Eastern Province.
Compare that to Alaska: at that time, there were seventy-one
per hundred thousand. So sixty-five in Saudi Arabia, seventy-
one in Alaska. Seventy-four in Mississippi in 1965. I m not
talking about the quality necessarily of all these physicians
150
or how they practice, but obviously an enormous explosion in
fifteen years. You might talk about evolution; actually, it
was almost revolution. And this continued on after that time.
So those are some examples of the changes.
I ve got some more statistics, but I m going to run into
them later.
Hicke : Do you want to say something about why and how this enormous
explosion took place?
Handschin: We were giving a good deal of advice to the Ministry of Health
in trying to get them to hire more physicians, more nurses in
particular. But mostly it was economic opportunity that
attracted doctors. There was money to be made, and that s why
these people flocked into take advantage of it. It was the
arrival of all these expatriates in particular: a large number
of Palestinians, Indians, and others who came there had been
accustomed to good health care.
Hicke: You were talking about the supply; now you re talking about the
demand side.
Handschin: So the demand side was there. And these people had money and
they could pay for the care; many of them had wives and
children, and they did pay for that care.
Crucial Leadership of Dr. Richard Daggy
Handschin: One thing I want to talk about is something about the
leadership by Dick Daggy, first as chief of Preventive Medicine
and then as medical director. He s the guy who recruited me as
an epidemiologist. He assisted in the recruitment of
industrial hygienist, maternal and child health physician, and
the nurse consultant. I actually recruited the occupational
health physician. He established the first disease reporting
system. It wasn t perfect. He did a lot of special studies of
particular disease.
He was the person who instituted malarial control. He is
the author of the definitive study of malaria in oases, a
published document. There were many springs in the oases,
from some of which water then flowed down canals. He
introduced a particular kind of fish that would eat the
Anopheles mosquitoes larvae as a malaria control mechanism.
He turned that malaria control pretty well over to the
151
government by "54. I think he was hired in
he did an enormous job of malaria control.
48. In six years,
He s the one who devised the idea that all these
preventive medicine people that he was bringing in should be
staff advisors to line operators. They should do the studying,
the planning; they should help expedite; they should evaluate;
but they should not directly operate most of the preventive
programs that were related to clinical care. Instead, the
curative doctors and nurses were made responsible for the
preventive programs in their own clinics, and they had to be
given in-service training that people had recognized as
necessary for preventive aspects. And not all clinicians
really relished this new role.
Hicke: Yes. And this was all devised by Dick Daggy?
Handschin: It is a tribute to Daggy.
During 61 to 66 there was increasing recognition that
one clinic should serve to provide both the preventive and the
curative care. In one sitenot a separate site. And then to
make every clinic visit an opportunity to review what
preventive means there might be, and how to address themand
how to dispense a pound of prevention with a pound of cure. So
there was widespread recognition that this was the way to go.
Daggy s concept was resisted by a certain segment of people who
were in curative medicine at the time. But ultimately the
people who started seeing it pay off fell in and found out
"Hey, this makes sense." That, I think, was his creation; all
I did was fit into the traces when he fell out and try to jog
along the same sort of way.
There was really a very heavy emphasis upon primary
prevention: preventing from occurring if possible. Then the
second step: early diagnosis. If it has occurred, let s find
it and do something about it, actually to treat it, and if at
all possible, in an outpatient settingwhere the patient is
still standing. We provided 450,00 clinic visits a year; 50
percent of our medical care costs were outpatient care. We
attempted to provide those outpatient physicians not only
suitable time to see the patients, but suitable supporting
personnel, the lab, an x-ray, the requirements that they
needed.
Principally this kind of care was under the direction of
general practitioners, but we provided suitable speciality care
to try and keep people out of a hospital. Because hospitalized
patients, in addition to their medical care had all the expense
152
of room and board: the equivalent of being in a first-class
hotel, the expense part. So it was an emphasis also in Aramco
--and this again came from Daggy--on using the lowest level of
skill which can competently do the job. And if that lower
level of skill is inadequate, we give them specialized training
or on-the-job training to upgrade it to a particular level that
we were comfortable with. Forty percent of outpatient visits
were attended solely by an appropriately trained nurse. Forty
percent. Nurses outnumbered doctors in the clinic four or five
to one, and they provided 75 percent of the care, mostly under
M.D. or under nursing supervision. So an enormous amount of
care was being done by nurses.
Hicke: Weren t you ahead of this trend in that?
Handschin: Oh, much, much more so. Way ahead. Ahead of what we were
doing in the United States too. And again, these are Daggy s
ideas that I believed in, and others did too. But he was the
leading proponent and he was the guy who sold it to management.
Management liked it too, because an estimated 20 to 30 percent
of our care was preventive care that was being delivered by
these nurses. Nurses were closer socioeconomically to the
patient than the physicians were. They could relate better to
the patients. And most particularly the nurses that we were
hiring cost from one-fifth to one-tenth what physicians cost.
Now how did the GPs interact in these large clinics that
were working with the dependent? GPs worked two days a week in
a screening modality in which they were working with several
nurses at their elbows. They quickly screened patients, and
determined what should be done for them that day--to whom they
should be referred. They would see maybe a hundred patients in
eight hours doing that. But they had only to say, "Nurse, do
this for this patient." And many of those patients got
referred to another doctor that day, immediately sometimes.
This was triage; this was sorting to determine what are
the skills that we have that should be applied to this
particular case, and then the doctor and the nurse jointly
making that decision. So that was a screening program. It
wasn t much fun, and some guys disliked it. They would spend
one to four minutes, maybe, with a patient, and then get them
into the hands of a nurse who was going to do something for the
patient. But then the other three days of the week, the
general practitioner went back to being an attending physician.
He then would see maybe fifteen patients, maybe twenty, but
fifteen commonly, and give them a more complete workup. For
every ten general practitioners working in a clinic, we had a
senior physician who just floated around and helped. He was a
153
Hicke:
Handschin:
clinical leader, chosen because of his capability, assistance
in diagnosing, assistance in handling and treatment, and so
forth. He was in charge of the clinic, but his job was
principally to serve as a consultant to these other people. He
himself might see a few patients that daythe more complicated
ones. But in the main, that s his focus. Again the idea being
using the lowest level of skill that can competently do the
job.
In fact, those clinics in the main handled about 98
percent of the outpatient care of dependents. Only about 2
percent at most ever were referred to specialists for
outpatient care, although we had about twenty specialists
available that we could send them to. So it was that the
general practitioner became a specialist in common diseases and
af f lictions--in their prevention, and in their treatment. They
really knew about a variety of things that they were seeing
most commonly.
The Preventive Medicine staff became responsible for
developing overall objectives and methods in disease prevention
and control. We developed manuals for tuberculosis control:
they gave some guidance as to what specific therapies were to
be used, what specific screening programs were to go on, how
you followed up on all contacts, how you got people to come
back in when they were supposed to come back in at certain
intervals, and how you related to the supervisors of these
employees. All this was spelled out in considerable detail.
And we had that not only for tuberculosis control, we had
manuals for maternal and child health programs too, so that
there was agreement between the clinic and the information that
we were providing to employees through our health education
program.
Aramco had a series of schools industrial training
schools. Remember, when we first started operating there, 98
percent of these people had not even attended an elementary
school. There was illiteracy. We began a big literacy
program. We ended up training many, many people to read and to
write. In that process, we put health education into that; so
we did that too. As long as you were learning to read, you
could learn to read about diseases or conditions of the
country, in the home and the village.
Did you write these manuals? Or your staff?
The staff. I assisted in critiquing many of them. We had
similar manuals, for instance, for hearing conservation, and we
had to have certain standardized approaches for immunization:
154
Hicke:
what immunizations should be provided; when they should be
provided. Not left to the judgment of the individual
physicians. He could countermand it if he had reason to.
Also, how do you teach cleanliness, which was an important
thing to do? How do you teach infant feeding? How do you
teach care of skin? and so forth.
All of these were things that the Preventive Medicine
staff spent time developing: working with the clinicians,
getting their ideas; finding out what was feasible and what
wasn t feasible; what would have been desirable but couldn t be
achieved because it was too boring or it was too demanding; and
so forth.
Amazing.
More Data on Patient Care
Handschin: I ve got some other things that I ve looked up.
Hicke: Good.
Handschin: In 1957, 40 percent of dependent infants who were hospitalized
in Aramco facilities died within twenty-four hours. Sixty
percent died before they were discharged. That was in 1957.
In 1967, ten years later, less than 10 percent died. This came
about by getting people in earlier, recognizing problems and
dealing with them on an outpatient basis. Between 1962 and
1967, we saw the deaths among dependent children due to
pneumonia, diarrhea, and malnutrition decreased by two thirds
in a five-year period of time. Deaths among children decreased
by two thirds.
Hicke: That s amazing.
Handschin: I don t think we introduced any marvelous new medications or
any great new procedures.
Hicke: No new drug discovery?
Handschin: It was better information on feeding, on earlier seeking of
care, telling people whom to seek out, and then finding out
more effective outpatient care.
Hicke: Can I just interrupt to ask you: did you feel this happening?
155
Handschin: Oh, definitely so.
Hicke: You could see it happening? It must have been very exciting.
Handschin: Yes, yes. That s what finally turned some people around who at
first thumbed their nose at this idea. When they began to see
the results, they would buy in. For instance, the big change
in tetanus: I don t remember the fifties, but the frequency in
which we were seeing tetanus in the newborn was just dropping.
It could be attributed to a program we developed.
Hicke: Very rewarding, it must have been.
Handschin: It was.
Between 1961 and 1965, the clinic visits per hundred
wives or children went up 24 percent; and that s within a six-
year period. But hospital days per hundred outpatient visits
went down by 24 percent. In other words, the most expensive
and often the most futile type of care--hospital care--was
significantly reduced; so that in a sense we began to look upon
hospitalization as a failure of medical care. People shouldn t
be hospitalized. They were hospitalized because they didn t
receive suitable medical care, including preventive care,
before then. They didn t have the proper information in order
to be able to do the sort of things they were told to do. And
that idea gained weight even in this country. It s just
recently that you find that hospitals now, instead of being
considered sort of the quintessence of care, there s now been a
great recognition in this country that many of these things
should not be done in the hospital; they should be done on
outpatients, or patients not even admitted to the hospital but
brought in as outpatients only.
Hicke: You were pioneering a philosophy of medicine, in a sense.
Handschin: Yes, yes, we were.
Hicke: That s really fascinating.
Handschin: In 1966 Aramco treated 300 cases of malaria, and only a few of
those were our own people. Most of those were general public.
Compared with 30,000 twenty years before. See, another example
of how things changed.
In 1952 there were fifteen non-Aramco hospital beds. By
1967, which was fifteen years later, there were six private
hospitals with 350 beds. In fifteen years, it s gone from
fifteen beds to three hundred and fifty. Two hundred and fifty
156
of those beds were in two hospitals that Aramco supported by
providing most of the inpatient load. But we also aided
government in addition to these private hospitals, and they had
680 beds in maybe eight government hospitals. You add all
those up and you came to 3.3 beds per thousand population
achieved by 1967. That compared to about five beds per
thousand in the U.S. at the time.
Need for Nursing Staff
Handschin: The major problems in the government hospitals at that time
were a critical shortage of nurses and of able administrators.
Often the administration was left in the hands of doctors, and
doctors aren t necessarily good administrators.
Hicke: I think Bill Taylor told me that Aramco had the first health
administrators in the Middle East.
Handschin: Yes. The biggest criticism that I could make of non-Aramco
care was the shortage of nurses. What that country really
needed was nurses--not doctorsmore than anything else.
Hicke: But there was a resistance, I think, to training women as
nurses .
Handschin: Oh yes, big resistance, yes. Probably in the long run the most
significant long term health event in the country was the
establishment of schools for girls in 1960. By 1967, seven
years later, there were already 25,000 girls enrolled. Before
that, nothing, nothing. Generally speaking, about 75 percent
of medical care in the U.S. is delivered by women- -nurses,
doctors, and so forthbetween 70 and 75 percent. Now even 50
percent of physicians, the younger graduates, are female.
So literate mothers, ultimately, are really a key to
having good health- -mothers who establish the family living
patterns and mold those--"Wash your hands before you come to
the table"--all these principles of good health and disease
control. This evolves from parent education, particularly of
the women who are the guardians of the next generation and
establish what s going to happen. That had not happened by the
time I left. These were kids in grade school,
course later, there must be higher education.
And then of
157
VI OVERVIEW: GOALS AND ACCOMPLISHMENTS
Handschin: I m going back down to one last thing on your outline. I m
going to spend a little bit of time talking about my own
experience as medical director and some of my reactions to
that, with my objectives and accomplishments.
One major objective I had was that you try to create and
then maintain a climate within the department that would be
conducive to delivering both suitable care effectively and
efficiently by a variety of professionals who themselves did
most of the planning and who themselves delivered most of those
services, who in large measure, by the kind of professional
training they had, were accustomed to self-policing of
reviewing quality of care, of being aware of other instances of
poor care that they might encounter.
In some respects, little of my time was needed to
maintain this aspect. It was mainly keeping people congenial,
making certain they were following up on quality control,
making certain they were aware that there were limits to
wasteful use of certain services, and also there was waste when
you failed to use other kinds of services that would be
beneficial. In the main, this was a professional organization
in which the professionals were running it. It wasn t quite as
bad as whatwho was it?--Hutchins, president at one time of
[University of] Chicago, who said something about: "A
university is a group of professional educators, all of whom
have only in common a public utility system."
We had a lot of interaction, but mainly these people
provided many of the ideas. I did spend a lot of time on that.
I had a lot of difficulty and a lot of time consumed in finding
people who were interested in change within that group- -who
were motivatedand finding those professionals who were
willing to undertake some kind of creative administrative
158
change that would be needed to increase efficiency or
effectiveness .
At best, I think that where I was most successful was in
identifying some of the more accomplished professionals and
helping them do their kind of job better- -people who were doing
an excellent job- -help them do even better and help them
because they were doing things that we wanted other people to
do. So help them propagate their ideas, abet them, and assist
them. In other words, I was getting the good people who were
already doing good things to help others do the same thing
better. A major portion of my time was really in assisting
good people to do things better than they had been. I had
ideas that there ought to be change, and these people were
suggesting there were changes; so I was seeking allies who
agreed with that and then working with them.
Hicke: It sounds like politics.
Handschin: It was. And I wasn t always, by any means, successful.
The second major objective I had was, of necessity in an
industrial organization, to transmit and to explain company
management s objectives, the company s interest, and the
company s policies. To transmit this I went to communication
meetings at least twice a week with top management, in which I
was exposed to things that should be transmitted downward.
This I did quite faithfully to maybe eight or ten division
heads that I had at the time. And I thought we did a good job
of that, a good first step. But I was often dismayed at the
trickle. The flow stopped at a trickle. And I admitted to
management that I was having trouble devising ways to enhance
its percolation in greater amounts downward.
I found that the Medical Department was not unique in
this; they were having problems like that throughout the
organizationof getting the information spread. There were a
variety of programs. They brought in a program called the
Managerial Grid. In fact, I participated in it. It was run by
some psychologists out of Texas, who had a very good program of
getting people to open up and learn how to recognize the skills
of the people they were working with, how to become team
members. Very effective program, although it was frustrating
to me. It wasn t much help to find out that other people were
having the same problem. Important things were not getting to
the proper people always.
Hicke: Do you have an example of something like that?
159
Handschin:
Hicke:
Handschin:
Hicke:
Handschin:
Not readily. [pauses] The company often had tosometimes
with advice from the government --make some decisions that were
not popular. And to be able to share those decisions explain
them, and explain the rationale for making them was one of the
duties I was expected to perform. I tried to do it. I enjoyed
doing it. Occasionally, we had meetings in which I would
address fifty or sixty top people. But mostly I dealt with
someplace between eight and twelve people. It was kind of
disconcerting to find that not everybody was quite that
interested in doing this. It was an annoyance, and something I
hadn t bargained for.
And maybe one final objective that I had was almost the
opposite, and that was to transmit to management and to others
in the company some things about the needs of the medical
department: the capabilities, the problems the medical
department was having, sometimes the successes and failures of
the medical department, the people within the department, and
the programs. I found this to be one of the most enjoyable
things I had to do.
It sounds as if you increased communications.
Yes. I felt it was useful. It made me feel highly creative.
I ve always spent a lot of time trying to be able to articulate
to people in a way they would understand why we were doing some
of the things we were doing in the medical department,
particularly each year.
You had a lot of successes to report,
things about doing that.
That s one of the nice
We did, we did. I was willing to really strive towards some of
these. I was willing to do that, because not all clinical
people would really like to spend a lot of time digging out the
data on how we are controlling costs, for example, which was
often an incessant question that came from management. How
efficiently were we operating? Or why we were failing to be
effective in training Saudi nurses? I wanted to lead a
creative team, and I was really strongly motivated to do that;
but I didn t think I was as effective in leading a team as I
would have liked to have been.
I left Aramco because I had a son who was mildly
retarded, born in Saudi Arabia. By the time he moved out of
kindergarten and the first grade, he was obviously uneducable
in that particular setting. He was not at an age where we
could board him, so we moved back here at that time. That was
a big disappointment, because I had all kinds of aspirations.
160
We had a group from Booze, Allen, Hamilton consultants out. I
had a lot of aspirations to become a more successful person, to
develop better leadership skills; and I never exercised them to
the extent I hoped for. But I had a lot of fun.
I learned a lot of things; I saw a lot of things. And
surprisingly, some of the things I d left there, I came here to
do, and started work here in a large cooperative that was
caring for about 100,000 people. I started beating the drum
for nurse midwives. Oh God! Our obstetricians here went up in
smoke. What? Ultimately, it was our consumers who demanded
more nurse midwives, and they got them.
Hicke: So you did some pioneering here as well.
Handschin: I did some things that they wouldn t believe in until I cited
some data. And then interestingly, I used some of that data
that I was acquiring here working with Group Health of Puget
Sound, which was a leader many times in using physician
assistants, as they were being trained. I used a lot of this
data when I then went back with Roger Nichols as a consultant
to the Ministry of Health.
Hicke: Oh, were you part of that corporation?
Handschin: Yes, that s right. I provided a lot of information to Roger:
staffing, and so forth. There was a melding of what I had
learned in Saudi Arabia with what I was learning from Group
Health here. So there was some continuation. But I m just
amazed at how--if I hadn t had some notes from speeches I had
to give there were vast areas of what we were doing out there
which my unprompted memory would not have brought back.
Hicke: I really appreciate your doing the research and bringing the
notes. You ve got it all organized so beautifully. But also,
you ve told me so much that I haven t heard anywhere, which is
surprising because I ve talked to a lot of people.
Handschin: If Dick Daggy were in his old health, I don t think anybody
could talk more. He had an enormous fund of knowledge that he
acquired, well thought-out. He had winnowed and sifted to find
out what were the essential things. He was the architect of
that system that I felt was kind of unique. We at least spent
some time interacting with other oil companies and their
programs . We were asked to come and talk about what we were
doing with Kuwait Oil, which I think of immediately, and with
the oil company in Bahrain. We spent a lesser amount of time
with the Iranians, although we attended clinical meetings of
the so-called Persian Gulf Medical Association, which was
161
Hicke:
Handschin:
Hicke:
principally people in the countries surrounding the Persian
Gulf who were affiliated with oil companiesmostly physicians,
though some weren t. There had never been any missionaries
operating in Saudi Arabia; there hadn t been missionaries in
Bahrain and the principalities along the Persian Gulf. But
there had been no other Western practitioners of medicine,
really. The first Saudi who graduated from medical school was
in 1948. And shortly thereafter, there were about five or six.
Unfortunately, most of those people had entered medical school
directly out of high school.
And they were weak in math and science. Most of them
didn t stay in the practice of medicine for long. That was the
early history in the fifties. There were some outstanding
Saudi physicians, including one that we helped to get a
master s degree in public health at Harvard.
Who was that?
Dr. Zowawei. Omar Zowawei. He had a charming wife. We
entertained them and they entertained us openly several times.
That s a good note to stop on and I really appreciate, as I
said, all you ve done. Thanks for a big contribution.
Transcriber: Lisa M. Vasquez
Final Typist: Caroline Sears
162
Regional Oral History Office University of California
The Bancroft Library Berkeley, California
Aramco Medical Department Oral History Project
Julius W. Taylor
SURGEON AND MEDICAL DIRECTOR: 1954-1978
An Interview Conducted by
Carole Hicke
in 1996
Copyright O 1998 by The Regents of the University of California
Since 1954 the Regional Oral History Office has been interviewing leading
participants in or well-placed witnesses to major events in the development of
Northern California, the West, and the Nation. Oral history is a method of
collecting historical information through tape-recorded interviews between a
narrator with firsthand knowledge of historically significant events and a well-
informed interviewer, with the goal of preserving substantive additions to the
historical record. The tape recording is transcribed, lightly edited for
continuity and clarity, and reviewed by the interviewee. The corrected
manuscript is indexed, bound with photographs and illustrative materials, and
placed in The Bancroft Library at the University of California, Berkeley, and in
other research collections for scholarly use. Because it is primary material,
oral history is not intended to present the final, verified, or complete
narrative of events. It is a spoken account, offered by the interviewee in
response to questioning, and as such it is reflective, partisan, deeply involved,
and irreplaceable.
************************************
All uses of this manuscript are covered by a legal agreement between
The Regents of the University of California and Julius W. Taylor
dated April 18, 1996. The manuscript is thereby made available for
research purposes. All literary rights in the manuscript, including
the right to publish, are reserved to The Bancroft Library of the
University of California, Berkeley. No part of the manuscript may
be quoted for publication without the written permission of the
Director of The Bancroft Library of the University of California,
Berkeley.
Requests for permission to quote for publication should be addressed
to the Regional Oral History Office, 486 Library, University of
California, Berkeley 94720, and should include identification of the
specific passages to be quoted, anticipated use of the passages, and
identification of the user. The legal agreement with Julius W.
Taylor requires that he be notified of the request and allowed
thirty days in which to respond.
It is recommended that this oral history be cited as follows:
Interview with Julius W. Taylor, an oral
history conducted in 1996 by Carole Hicke
in "Health and Disease in Saudi Arabia:
The Aramco Experience, 1940s- 1990s, "
Regional Oral History Office, The Bancroft
Library, University of California,
Berkeley, 1998.
Copy no.
Julius W. Taylor, July 1998.
163
TABLE OF CONTENTS- -Julius W. Taylor, M.D.
INTRODUCTION by A. P. Gelpi 164
INTERVIEW HISTORY 165
BIOGRAPHICAL INFORMATION 166
I BACKGROUND, EDUCATION, MILITARY SERVICE 167
II JOINING ARAMCO 170
Interview and Appointment 170
Moving to Dhahran, December 1954 171
III DHAHRAN HEALTH CENTER 174
History 174
Patients and Cases 175
Concession Agreement 175
OB/GYN; Burns 177
Dental Service 177
Trauma 178
Staff Personnel 179
Smallpox 180
Medical Care Responsibilities: Dependents 182
Facilities and Living in Dhahran 183
The New Hospital 186
Developing Psychiatric Care 187
Accreditation 189
Medical Training 194
IV CAREER DEVELOPMENT AND RESPONSIBILITIES 196
Chief Surgeon, 1961-1963: Hiring Staff and
Relationships with Management 196
First Open-Heart Surgery at Aramco 201
First Lung Removal 201
Evacuation Procedures 202
Contract HospitalsAnother Change 203
Attractions of Life with Aramco 204
Chief of Staff, Clinical Services, 1963-1968 210
Dental Care 210
Administrative Matters 212
Medical Director, 1968-1978 212
More on Contract Hospitals 215
Medical Care for the King and Royal Family 218
Early Saudi Medical Practices 221
Preventive Medicine and Research 224
Tapline Stations 228
Recruiting and Hiring Staff 229
Impact of Increasing Saudi Ownership Participtation 232
Emergency Preparedness 235
A Riot in Dhahran 237
V OVERVIEW 240
164
INTRODUCTION--Julius W. Taylor, M.D.
Dr. Taylor came to Dhahran, Saudi Arabia, in 1954, fresh out of a
surgical residency training program at Kingsbridge VA hospital in New
York. In Aramco s Medical Department he served as a general surgeon,
then successively as chief of Surgical Services, chief of Clinical
Services, and finally, as medical director. Not only is Dr. Taylor a
talented surgeon, but he demonstrated, early on, a gift for organization
and leadership, most effectively demonstrated during his years as
medical director. But Taylor lost neither his interest in surgery nor
his surgical touch as he moved up through administrative ranks. Among
his other accomplishments, he published the first paper on the
epidemiology of cancer in Saudi Arabia.
Bill and his wife, Lois, were very active in Dhahran community
affairs, in tennis, and in gracious entertaining. They finally left
Aramco in 1978, settling in New England, where Bill ultimately took on
leadership of Boston University s Student Health Service as its medical
director.
Armand P. Gelpi, M.D.
December 9, 1997
Sonoma, California
165
INTERVIEW HISTORY--Julius W. Taylor, M.D.
Dr. Julius W. [Bill] Taylor was with Aramco from 1954 to 1978,
serving as assistant chief surgeon, chief surgeon, chief of staff,
Clinical Services, and for his last ten years, as medical director. His
recollections thus cover twenty-four years at Dhahran Health Center-
years that were crucial in the growth of health care in Saudi Arabia and
in preventive medicine and other public health programs fostered by the
company .
Taylor s recollections cover a broad area concerning the Aramco
medical department. He discusses patients and diseases, research
undertaken, medical response to trauma, hospital administration and
accreditation, outreach efforts, contract hospitals, and life as the
Aramcons lived and enjoyed it in Saudi Arabia. Reporting to oil company
management presented an unusual situation for a surgeon and hospital
directorand that was only one of the many unique aspects of Taylor s
career. The anecdotes he recalls illustrate the interest of life in
Dhahran and demonstrate his enthusiasm for his work. He proved to be a
fascinating story-teller and an informative narrator.
Taylor was interviewed on April 18, 1996 in his office at Boston
University Student Health Services where he has been director since
1988. The transcript was lightly edited by the interviewer, then
reviewed carefully by Taylor. He made many corrections which helped
clarify and explain the information, and added useful and enlightening
comments .
Carole Hicke
Project Director
January 1997
Regional Oral History Office
University of California, Berkeley
166
Regional Oral History Office
Room 486 The Bancroft Library
University of California
Berkeley, California 94720
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167
I BACKGROUND, EDUCATION, MILITARY SERVICE
[Date of Interview: April 18, 1996] II 1
Hicke: Let me start by asking you when and where you were born.
Taylor: I was born in Holtville, California.
Hicke: What was the date, please?
Taylor: 12/12/22.
Hicke: And did you grow up there?
Taylor: I grew up there for eight years. My father was a truck fanner, so
we ran a little farm down there in southern California. I was
there for eight years; he was there for a little longer. After
that, we moved back to Kentucky, where my family was originally
from. We re from Kentucky, basically.
Hicke: Where in Kentucky did you live?
Taylor: We moved to Louisville.
Hicke: Now, let me ask you how you got interested in becoming a doctor.
Taylor: That s very simple. My mother was what we would now call a
medical assistant. She worked in a doctor s office in Holtville
and Louisville. There was a doctor that she worked with for
several years. And so as a result of that, she was convinced that
my brother or I should become a doctor. As long as I could
remember, she was saying that: "When you grow up, you should be a
doctor." When I was little, that didn t mean much to me; but
later on, people would say, "Well, you re going to be a doctor?"
This symbol (##) indicates that a tape or a segment of a tape has
begun or ended. A guide to the tapes follows the transcript.
168
and that s how it happened. So I just took the doctor s track and
stayed on it. It was my mother s strong influence that resulted
in that.
Hicke: How did you pick your university and medical school?
Taylor: It was interesting because when I was in pre-med and the--
Hicke: Where was that?
Taylor: I went to DePauw [University] initially, but I had to leave there
because my father got sick. As I finished up pre-med at the
University of Louisville, World War II broke out; we were just
automatically enlisted and designated to go to the University of
Louisville. They called it ASTP, which is the Army Specialized
Training Programalso quaintly known as "all safe till peace"
unit.
Under that program, medical school was sped up then: you only
went three years, as there was no summer vacation; you just went
right around the year. I think you had a couple days for
Christmas and the holidays, and that was it. We got through
medical school in three years instead of four. I graduated from
the University of Louisville Medical School in 1946.
Hicke: Did you have to go overseas?
Taylor: I had an internship in New York, and in that little interim there
somewhere, the war in Europe ended. So while I was in the
internship, I was still retained in the active reserve, which
meant that I was still at their beck and call. When we finished
the internship in 1947, I went into the military on active duty
for two years.
Hicke: Where were you?
Taylor: First, I was in San Antonio, Texas. Then I was transferred to
Belleview, Illinois, which was Scott Air Force Base, completing
two years of active duty.
Hicke: Were you in the air force?
Taylor: At Scott Air Force Base, I was in the air force. As a matter of
fact, the air force used to be part of the army. And then they
split, so the air force became an independent arm of the military;
so I transferred into the air force. I was in the air force for
the last year of my active duty.
Hicke: And what did you do when you got out of there?
169
Taylor: I went into a surgical residency then, back in New York at the
Kingsbridge Veterans Hospital. I spent four years there, from
1950 to 1954.
170
II JOINING ARAMCO
Interview and Appointment
Hicke: Now, how did you happen onto Aramco?
Taylor: An interesting thing happened: a predecessor of mine at the
Kingsbridge Veterans Hospital, a fellow named Dr. Johnson, had
gone over to Aramco and done one tour, and was coming back.
Hicke: What was his first name?
Taylor: I don t remember.
Hicke: He must have been there very early.
Taylor: He had a tour of surgery there for two years. He came back, just
passing throughhe was on his way to Philadelphiasinging the
praises of Aramco, what a wonderful time he had, and how much
exciting surgery he did, what an exciting adventure it was, and so
forth, so on. After I talked to him, I decided I really wanted to
do this. He said, "Well, my job is open." He called up Aramco
at that time, one of the bases was in New York and I talked to a
doctor named Ted Allen, who was the medical director in the
States. We talked, and subsequently I was employed for that job.
That s how that happened.
The residency was hard work; I d been there four years. I
thought, "Well, I m going to do this. It s going to be fun." And
I d gotten married just at the time my residency started, so we
were going to take a little world trip and have some fun after
that, and just enjoy ourselves, at least for one two-year
contract. So that s how it started.
Hicke: And you figured on two years?
Taylor: Two years. At most. [laughter] That didn t work out that way.
171
Moving to Dhahran, December 1954
Hicke: Tell me what your impressions were of Dhahran and the health
center when you got there. This was 55 that you moved there?
Taylor: No, "54. 1 was supposed to finish my residency through December.
Aramco said, "Oh, no. We need you badly. We ve lost a surgeon.
And we have to have you right away." In fact, they became very
adamant about it: "You must go now." So I actually left the
States on December 11. I left my training programthe people
running it at the hospital were unhappy because they had to cover
me for that. And that was not easy, since that included
Christmas, and people wanted off for Christmas. But I ll never
forget the New York office; Ted Allen, in particular, said
something like, "Either go now, or you re not going to get the
job." So I finally got everything together, climbed aboard the
Flying Camel, one of Aramco s transcontinental airliners, and
began what turned out to be a lifetime overseas adventure.
When I got there, I was appalled when I found out they didn t
know I was coming. I thought, "This place isn t as well organized
as I thought." Because I m standing in the airport building
which, at that time, was a World War II quonset hut. It was wide
open; it was noisy; there was nothing. And when you first went
in, you thought, "This must not be it." [laughter]
Hicke: Wrong place.
Taylor: So I was just kind of standing around, and I remember a woman,
whose name was Johnnie Rusher, came up and said, "Are you our new
employee?" I said, "Yes." She said, "What s your name?" I told
her. She said, "Well, you re not on my new arrivals list."
"Well, by chance," she says, "The chief surgeon is a fellow named
Lonas, Hal Lonas. Hal happens to be here meeting his children who
are coming home for Christmas." So she took me over and
introduced me to Hal Lonas; and he said, "What are you doing here
now? I said, "Well, Ted Allen told me the surgery cases were
backed up and I was needed desperately." He said, "Well, we re
very slack now. We re slow. It s Christmastime. I can t imagine
you came here and missed Christmas at home." And I said, "I can t
imagine it either." [laughter]
Hicke: So you would say there was maybe a lack of communication--
Taylor: Definitely.
Hicke: --between New York and Dhahran?
172
Taylor: Well, Lonas, who was my chief, mentioned that he knew they were
interviewing me. But he said, "I haven t gotten any information
that you were hired or that you were coming." In those days,
communications were obviously not as quick and accurate as they
are today. So there was frequently a lapse in the communication,
Sometimes this was funny; sometimes not so amusing.
Hicke: Are we talking about technological lapse or a lapse in a--?
Taylor: Technological, because mail in those days, even air mail, special
delivery, whatever you did, would take two or three weeks to get
from New York to the field.
Hicke: There was no telex?
Taylor: Yes, but only for important messages. Even telephoning was very
difficult. It wasn t until the seventies that you could finally
pick up a phone and call the States. And even today, if you pick
up a phone and try to call Aramco, you ll run into a little
trouble, but not like those days. Sometimes the message simply
did not get through. The next time I saw Ted Allen, I said, "What
was all that about?" He said, "Well, I had to get you out there,
and I wanted to get that done." I told him, "They didn t happen
to know I was coming." And he said, "Well, they should have."
In those days, your wife couldn t go with you when you went.
Aramco had learned that when husbands and wives came together, all
too often they said, My god, what have we done? And they would up
and leave, and for good cause. In those days, it could be rugged
going; it was a far cry from Stateside living conditions. So
wives would come, and after a short time, they would say, "This is
crazy. I m leaving." So Aramco decided that the best way was to
bring in the employee, let him get settled, and then bring out the
wife at least into more reasonable circumstances.
It s hard to describe the emotional reaction, because it was
departure from a Stateside routine into a strikingly different
existence in Saudi Arabia. A far cry from the U.S., Europe, or
even the Orient. It was simply too much for many new arrivals,
and they would turn around and go home. This expatriate life
demanded rugged people, both in body and soul.
Later on, as I went along, I met a newly hired woman doctor.
She too was welcomed at the little quonset hut. She walked down
the steps, and I was there to meet her. She looked around and she
said, "This is it?" I said, "Well, this is the airport." She
said, "You re kidding." She went over to the counter, and she
said, "Don t even put my bags through." She never left the
173
airport. She got back on the same plane and took off for India.
That was our shortest hire of all time!
Hicke: You wonder what she was expecting.
Taylor: It was a hot day. When you walked down those metal steps, your
feet would burn. When she stepped out, it was probably 110
degrees F--and it was very hot. Between that, a little sandstorm,
this hut, and the customs people one had to go through, it was too
much for her. And in retrospect, she probably did the right
thing, when she quickly decided it wasn t for her.
So when you got out there, you have this delay with your wife
coming. Aramco finally shortened it to six months. When your
wife arrived, you had to caretake houses, because you couldn t get
your permanent assignment. We moved six times before we got into
our house. That gets to be a drag when you keep moving around.
You might get a good house, you might get a lousy place, you know.
So that was an indoctrination in itself. In fact, I ve always
wondered if my wife stayed because of the adventure and travel or
because of the challenge. She s a New Englander, and she liked
the New England area, and this is just about as far away from that
as you can get. Anyway much to my surprise, she stayed and
stayed.
174
III DHAHRAN HEALTH CENTER
History
Hicke:
Taylor:
Hicke:
Taylor:
Tell me about the Dhahran Health Center,
when you got there?
What was going on there
Well, the health center was in a state of early development and in
the early stages of providing comprehensive care.
Can you tell me about Dr. T.C. Alexander?
Dr. T.C. Alexander was the pioneer doctor of Aramco medicine. He
was the first doctor. When he started, he had a nurse and a first
aid station in a little building. He continued on several years
after I arrived. As I heard it, he was with the American oil
group. In fact, he was sort of a legend, because he was
originally in Bahrain, and when oil was brought in at a wildcat
drilling site in Dammam, he came to Dammam and set up a medical
station. Dr. Alexander was legendary and people came from far and
wide to see him. After it was established that there really was
major oil in the area, he moved to the Dhahran compound. They had
this very small, almost like a first aid station. He was a well-
trained general practitioner, so he did a lot of things: he did
surgery--f ixed hernias, did appendectomies under spinal or local,
which was pretty rugged stuff. In those days, there was a good
British hospital in Bahrain run by Dr. Snow. It was my
understanding--! wasn t there then, obviouslyif anybody got too
sick for Dr. Alexander to manage, they d take them over to Bahrain
and treat them over there.
They went from a tent, actually, as I understand it, into
this little building. Around that building they built their first
small hospital. It was rustic; it was like World War II. You
have to remember this is right after World War II, and a lot of
these people that were there were veterans of World War II. Hal
Lonas was a commander in the navy as a surgeon. He was the chief
175
surgeon, and there was a chief of medicine, a fellow named Curtis,
and several others. Dr. Robert Page, at that time, was the
medical director. When I arrived there was a Dutch surgeon, Peter
Van Dooren, an Indian surgeon, and an Arab surgeon, Dr. Fyak Abdi,
who later became chief surgeon.
The thing about the hospital which remained true throughout
was that the hospital care evolved slowly but surely along the
lines of current American medical care. There was never a clear-
cut policy as to who decided what level of medical work would be
done. So the medical work that was done there was like in a field
hospital in the military. We operated, and we did all kinds of
traumatic work as well as medical work. Today you d say that was
primitive, but in those days, it was consistent with a good
military hospital.
We had all the modern drugs we needed. We had good operating
rooms and good supporting services. Good x-ray and lab
facilities. In general, the hospital worked at that level, which
was quite good. Excellent records were kept on all patients, both
inpatients and outpatients. The people there were well trained:
most of the top professionals were board certified. Dr. Lonas was
a board-certified surgeon. Dr. Robert Page, as a matter of fact,
was a board-certified internist. Fred Howard, M.D. was chief of
Pediatrics. Dr. Curtis was chief of Medicine. There were two
G.P.s who headed up the OB-Gyn section: Dr. Robert Brown and Dr.
Ivor Morganin fact Dr. Brown delivered my son, Scott, in 1955,
Dr. Morgan my daughter, Sandra, in 1958.
Patients and Cases
Concession Agreement
Hicke: Who were the patients, besides Aramco employees?
Taylor: The patients were the same from the beginning. Gelpi was looking
for the original medical agreement with the government. I read it
once in some book.
Hicke: Oh you did? I ve inquired myself, and was told that nothing was
written down.
Taylor: I m just recalling this from long ago. It was a one-sentence
agreement; and it said in the concession agreement that "Aramco
176
would provide medical services to all employees and their
dependents in that area." That s all it said.
Hicke: They put it in the original concession?
Taylor: That was in the original concession. You ve got to remember, when
that concession was written, in 1936, there were only about fifty
Americans there, and very few Arab employees. There were very few
dependents at that time. This was a pretty barren area in those
days. Most of the Arab employees migrated there. They didn t
start there, so their families were not around. I think I read
somewhere the original total responsibility was something like 300
people. There were about fifty Aramco guys; the nurse was there;
very few women, two or three women as employees; and originally,
there were maybe only sixty-seventy Arab employees. Because at
first, they were just exploring, and the first well, Dammam No. 7,
was a small producer. So that original concession agreement was
very simple. Nobody ever anticipated at that time what the
medical program would eventually amount to. In 1968 there was a
direct medical responsibility for 40,000 employees and 160,000
dependents and an indirect responsibility for major illnesses of
the 2 million people in Eastern Saudi Arabia. The president told
me one day, "We do more medical business here than we do oil
business!" [laughter]
Hicke: Who was the president?
Taylor: Well, there were several presidents during my twenty-five years.
[Added later] There was one thing they had in common: The Aramco
medical repsonsibility was low on their list of concerns. From my
viewpoint an Aramco president wanted good, middle-of-the-road
medical care. This meant we should be able to manage all run-of-
the-mill medical problems as well as a small-town hospital in the
States. I agreed with this level of care. What we did we did
well, but we were not a Mayo Clinicthis meant that everyone
dependent on us ran a certain medical risk by working in Saudi
Arabia. We did not have surgical or medical specialists. [end of
insert]
Hicke: Did you know Tom Barger?
Taylor: Fred Davies was president when I first went there. He was one of
the original guys, as was Tom Barger, by the way. Fred Davies was
the president when I got there, and after him came Barger. I knew
Tom Barger quite well and took care of him and his family many
times. Originally, it was a small MASH-type outfit; later this
hospital was built. As a hospital, it had three wards on it:
medicine, surgery, and OB/GYN. It had two well-equipped operating
rooms; it had an x-ray unit in it. And the surgical equipment was
177
all good; it was modern and geared for the level of care we
intended to deliver--"we" being somebody else who decided what we
were going to deliver.
OB/GYN; Burns
Taylor: At that time, there were very few women, so obviously very little
American OB/GYN work was done in the early years. That was a
minor little side. But there were Arab women who came in there
for deliveries, so we did have the OB/GYN ward. Of interest, Arab
husbands frequently insisted on being present for pelvic exams.
One ward was set aside for burns, because there were many
burns. They used a British stove called a Primus stove, and that
stove was dangerous. The clothes of the Arab people were long
flowing dresses and robes. It was all too common for the stove to
explode when it was being pumped up for use, and these robes would
catch on fire.
Hicke: Is it a cooking stove?
Taylor: Well, it s one of those things you pump up and get the pressure on
the gas. You cooked on it and used it for heat as well. Thinking
back, I think most of the fires occurred when they were lighting
it. Because you d pump it up, and then I don t know what went
wrong, because it would puff out with a flame and catch them on
fire while they were trying to light it, causing severe, extensive
burns. These patients frequently died, and if not, were on the
burn ward for months for treatment and skin grafting.
Dental Service
Taylor: Early on, we had a dentist. Initially he did fillings and
extractions.
Hicke: Did he have the necessary dental equipment?
Taylor: Yes. He had a small office with what we would think of now as
essential equipment. He drilled out cavities and put in fillings,
pulled teeth, fixed broken teeth, and that sort of thing. He was
a very good general dentist. The dental service grew rapidly and
later expanded into the biggest dental unit in the Middle East.
Still is today.
178
Hicke: That was while you were there.
Taylor: Yes. I think they were building up to fifty dentists, covering
every phase of dentistry. We had all the subspecialties. It was
kind of interesting, because dental was easier to recruit for.
Bernie Eggerman became the chief. He was an enthusiastic,
dedicated, and well-connected pusher, and so he got a lot things
done for dental, which was very good for everyone. They
eventually offered quality dental care to all Aramco workers and
their families.
Trauma
Taylor: The biggest problem in those days was trauma, because Arabs loved
big American cars, and the roads were absolutely hopeless: no
lights, no lines, no signs. It was just a strip of asphalt
through the desert, through the easiest way they could go, and
often drivers would simply cut across the desert; so they d go
over hills, around curves at break neck speeds, and it was
extremely dangerous. The Arabs were not unlike the rest of us--
loved to drive fast.
The other interesting thing worth noting was that the Arabs,
like earlier days in the U.S., would hitchhike all the time. It
was almost an obligation for the Arab, if he saw somebody waiting
along the road, to pick him up. So the cars were usually full of
people; when they d collide, as they often did, there d be a
helluva wreck, usually with multiple major casualties.
Literally, it was not unusual to have our ambulances bring in
ten or twelve mangled people all at once. In the early years, up
to 1965, Aramco had the only ambulances, and they would range long
distances to help the injured.
Hicke: Can you describe an example?
Taylor: The worst accident I ever managed in heading up our ER [emergency
room] happened to a big bus full of people coming back from the
Had j . They had pulled off the side of the road, but not far
enough; Half of the bus remained on the road. I don t know what
was wrong with the bus; it had stopped, so all the people were
sitting there. This huge truck came along with a big grading
blade which was up, and that blade went along and just literally
sheaved off the outer half of the truck. I ve forgotten how many
got killed. I think about twenty. However, there were another
thirty badly injured people screaming in the night pretty far from
179
Hicke:
Taylor;
Hicke:
Taylor:
this hospital. So by the time they were gotten to the ER, another
five or six had died. That was the worst accident, as far as road
accidents were concerned.
Such accidents were frequent,
major trauma on the highways.
Mostly Arabs?
Very few days passed without
Mostly Arabs. Occasionally, an American. Americans were wary:
they wouldn t drive at night if they could possibly help it; they
realized that these roads were dangerous. Arabs didn t think of
them as being dangerous. So it was mostly Arabs who got smashed
up in these automobile accidents. It s still true today. They ve
never done much to improve the road; at least when I left, there
were still no lines, no signs, no curves. I think they finally
got stop lights in some places, but out on the highways, it was
every man for himself. And there were no speed limits; they d go
like the blazes, you know. And so it was a setup for trouble.
That s where we got our most demanding medical work. I never
ceased to have a little chill when called. In a "big crunch" the
emergency room patients would be all over the place, sometimes on
the floor or on the gurneys, sometimes stacked up on the ambulance
platform.
Did you call on every doctor available?
No. We d just call in the surgeons.
Staff Personnel
Taylor: When I first got to Aramco, there were six surgeons. Three were
trained as board surgeons; the other three, who had become
surgeons had become skilled in the hard school of experience. We
all became trauma experts.
Hicke: Were these all Americans?
Taylor: Oh no. In fact, Dr. Lonas and I were the only two Americans at
that time. There was one Saudi, Fyak Abdi; one Dutch surgeon,
Peter Van Dooren; and one Indian surgeon, Cecil Smith from Bombay.
Later we added a surgeon from Beirut whose name was Dr. Mikhail.
He was an unusually brilliant and talented surgeon. That made up
the surgical staff during my first tour of duty. Dr. Lonas was
the chief, I was the assistant chief, and all of us worked
together as a team. These surgeons were fearless and hard
180
working. Two of us were on call every third night and since very
few nights went by without surgery, we were in the hospital eighty
to 100 hours per week.
ta
Taylor: One of the things that was interesting about the surgical theater
was that the anesthesia was always given by a nurse anesthetist.
Our statistics on anesthesia were surprisingly good. These nurse
anesthetists were there for many years. They were very cautious;
anesthesia was very light. These four American nurses did a
remarkable job over all the years I was there.
Hicke: So they could probably administer but not handle emergencies?
Taylor: On the contrary, they were super with emergencies. They stuck to
very simple anesthesia. The anesthesia they did was very safe and
it worked. There were four anesthesia nurses available most of
the time. If there was big troublewhy , we d get as many of them
as we needed, usually two or three of them. Usually, we d run two
O.R.s [operating rooms] at once, so there d be one anesthesia
person in each one. That was the surgical part. If you have
watched the MASH programs, there was a striking similarity to the
Aramco surgical world.
It should be understood that at the same time we were
providing a full range of medical care. There was a medical ward,
pediatrics, and OB/GYN. However, of special interest, there was
no psychiatry service in the early years. There was no need.
Americans were sent home. Arabs didn t go psycho.
About five years after my arrival, a new hospital was built.
The medical business was increasing rapidly and more sophisticated
demands were being made by the patients. The old equipment, the
sandy O.R.s, the one-room lab, and waiting out in the sun to be
seenthese were some of the problems that had to go.
Hicke: And this was nearby, across the road?
Taylor: The hospital was built on the main access road so that Arabs had
quick and easy access--95 percent of the patients were Arabs.
Smallpox
Taylor: One interesting fact: when I first got there in 1954, they were
having what was probably the last smallpox epidemic in history.
181
They had a little isolation building that they used. I was called
to see one of the smallpox patients who had some kind of surgical
problem, which turned out to be appendicitis. I went over there
and took care of it. There were about ten patients in there with
smallpox. As far as I know, I never saw case of smallpox after
that in my life. Even though we were all vaccinated against
smallpox, everyone taking care of these patients was very nervous.
It s one thing to be vaccinated; it s another thing to be exposed
and hope the vaccine works. It did.
Hicke: These were Arabs?
Taylor: These were Arabs. And this kicked off, with Aramco s help, a
nationwide effort to vaccinate everybody for smallpox. Up until
now the vaccination program had been spotty. Arabs didn t like
being vaccinated. But now a royal decree came down from Riyadh,
and nationwide vaccination was carried out.
Hicke: Which had not been done before?
Taylor: Well, some of them were vaccinated, but now all Saudis were
vacinated by royal decree.
Hicke: The youth had had some vaccinations?
Taylor: A lot of them had been vaccinated, but many had not. Some of
people came from Yemen, which is south of Saudi Arabia, and had
not been vaccinated. We hoped that was the end of that. One
thing--! don t believe it s known to this day whether everyone is
vaccinated for smallpox there or not. As you know, smallpox
vaccination has been discontinued worldwide, because everybody
thinks it s finished, you know, there won t be any more smallpox.
But I often think to myself, maybebecause there must be areas in
that part of the world they ve never heard of a vaccine for
smallpox. To believe that smallpox is really eradicated is highly
optimistic. Since the Western world will soon have no immunity,
an epidemic would be catastrophic.
So I think it s a little optimistic to think that it s gone
forever; but so far, so good. And there haven t been any cases
for a long time. So maybe it is finished. I hope it is. But
that was an interesting thing to start with, a little smallpox
epidemic; most medical people have never seen a case of smallpox.
To be in on the last of the smallpox epidemics was a very
interesting and exciting way to begin this fabulous adventure.
Hicke: How did they deal with this?
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Taylor: The Arabs never fully understood the potential of a smallpox
epidemic; very few even knew it happened. One must remember there
was no dissemination of news about such things. However, the
Arabs living in the Eastern Province knew about the Aramco Medical
Center and would come long distances to be treated. No Arab was
ever turned away, nor was anyone else who needed the services.
However, once we had done all we could, then they had to leave our
system.
Medical Care Responsibilities: Dependents
Hicke: It also raises the question of who you were responsible for.
Taylor: We got that clear, eventually, because what it boiled down to was
very clear-cut: First we were responsible for all Aramco employees
and all their dependents. This included all employees; at times,
there would be as any as twenty different nationalities working.
We can take a second to discuss the dependent situation,
because there was a long- running argument about that for many
years. What Aramco regarded as a dependent was a wife--or wives,
because many Arab employees had more than one wife and the
employees children. Well, at one time, the average number of
children was something like twelve. Average. So there were many
families with eighteen, twenty, twenty-four kids. The number who
had four wives was small; I think at one time it was like 10 or 12
percent of the employees had four wives. On the other end, there
was 10 or 12 or 15 percent who had no wives: they weren t married
at all. The biggest number of married Arabs had two wives; three
wives was next; and then four wives was the least. This created a
large dependent population of approximately 600,000. We provided
quality care for all of them.
Now, what the Arab thought were his dependents were all the
people who lived in what he called his villa; this often included
more categories. Then Aramco had bargained for brothers and
sisters and their children. Aramco decided the best plan was to
just take care of all of them. So if an employee would come in
with a boy, we d take care of him. We learned our lesson: I
persuaded Aramco management that we would just take care of all of
them. We would have lost far more in our rapport than we d ever
save in money. The actual cost add-on was negligible anyway.
The second part of our obligationwhich was clearly
understoodwas we would provide medical care to anybody who
needed medical care that was not available outside of our
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Hicke:
Taylor:
facility. And in the early years, that was everybody, because the
local facilities were very, very spartan and meager. They had few
specialists and inadequate equipment. So if a general public
patient was diagnosed with appendicitis and he went to the local
hospital, they would send him up to us.
On our side, we had complete backing of the government; if it
was somebody that we couldn t do anything for- -even if they were
dying, like an advanced cancer casewe wouldn t take them. They
had to go home, because there was nothing we could do for them.
So we were very firm about only taking general public patients who
were people that we could do something for medically. Once we had
done what we could, such as take out an appendix, we d send that
patient home in a couple of days or send him back down to the
local hospital, because the local hospitals did have beds and they
did have facilities, but their doctor supply was limited. As far
as I know, that level of responsibility still holds; so that even
now, if somebody comes in who s not eligible and they have
something that the local facilities can t handle, SAMSO [Saudi
Aramco Medical Services Organization] will take care of it.
Who established those guidelines? Do you know?
I was the one who finally crystallized those guidelines, along
with Aramco management. In a sense, and rightfully so, the
administration out there and the parent companies thought of the
medical system as a necessary evil. We had to have it for almost
everyone. Once you have something for the Americans, you
certainly won t deny the same level of care to the Saudis. It s
also very difficult to say, "Well, we re going to have a good
medical facility, but only for the employees, or only employees
and their dependents, only employees and their real dependents."
In other words, trying to delineate such fine lines was
politically ill-advised. In looking back, any other decision
would have been stupid.
Facilities and Living in Dhahran
Hicke: That s really interesting, because I think that happened in other
than medical areas too, like electricity and water and air
conditioning.
Taylor: Well, the AC, the air conditioning, was always a bone of great
contention. It used to be amusing, because they used to call the
Arabs who were inside the compound "AC Arabs," and that was a
derogatory term. I heard guys say, "Oh, you re one of those AC
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Hicke:
Taylor:
Arabs"--like you were a bad guy, you know. Health bears on it to
some extent, because there was always an intense effort early in
the early years for the Arabs who wanted to come into the compound
and live inside the compound. At the same time, there was an
intelligent and logical resistance to this, because there was such
a difference in the social structures that this integration was
very difficult. It wasn t easily done, and created major societal
problems.
One day, an unusual Aramcon named A.C. Hill came in with what
he thought was a solution. He was an American guy. He said,
"I ve got a better idea. We ll build good housing for these guys
out in the communities. We ll put in AC, we ll put in running
water, we ll put in toilets." And they did. That solved one of
the most difficult problems of all, because the interesting part
of it was the Arabs actually had more difficulty living inside the
camp than the Americans had with the Arabs. The Americans would
come in, living their way of life; and a lot of our customs were
not acceptable to the Saudis. As their children grew up, they
were subjected to the peer influence of our young crowd. And they
didn t like that. The schism between the Americans and the Arabs
was too wide and there was no meeting of the ways; it caused
endless animosity.
So when we offered this solution, they thought it was great.
In fact, as of today, the executive Arab compound is much better
than the American compound- -beautiful. We built it right outside,
just across the road from the hospital. They didn t have to, but
they wanted to: because these were better houses. There were the
same kind of people living around them; and they had their own
community; and they had all the amenities they could have inside
the camp. That was a great solution. Up until then, it was
becoming more and more of a very sore point, because the Arabs
were saying, "Look, you Americans are living in there. You ve
got--." AC was their main complaint. "We re out there in the
heat!" So remedial steps were taken, and the problem was solved
by A.C. Hill.
Did you see a lot of problems caused by heat in the Americans?
No, oddly enough, because the only time we had problems was when
the Americans would overdo it. They used to run a marathon, you
know, as a sporting event. So Americans would runI ve forgotten
how far they ranbut it was like twenty miles, and they d get
heat exhaustion. But you have to remember that the heat was only
serious between July 1 and November 1. Up until then, it s like
southern Florida; so in the winter, it was cool and the weather
was generally good. So the hot weather was really mostly July,
185
August, and September and then it was really hot.
over 100 degrees, sometimes 120 degrees.
Almost always
Hicke:
Taylor:
Hicke:
Taylor:
Hicke:
Taylor:
Hicke:
Taylor:
The other thing that had a big influence on the reaction to
the weather was that it was right on the Gulf. When the winds
blew in off of the Gulf, it was very, very humid, and it was so
humid that the AC couldn t handle it. So the temperature inside
the houses would go up into the eighties. That doesn t sound like
much, but somehow or another everybody thought it was too much.
The humidity certainly added to the discomfort.
The humidity was bad, the heat was up, and people would get
irritable and everybody was in a bad mood when that would happen.
Most of the time, the winds were from the north; shamal is
the word for the north wind. When the shamals were on, they d
blow dust and sand all over the place; there d be dust storms,
sand storms. But most of the time they were blowing out into the
Gulf, so you didn t have this intense combination of heat and
humidity. But the shamals I Sometimes they d last two or three
weeks; these shamals were wicked. The sand would come through the
doors, in the windows. You d have to clean up everyday. Where I
lived initially, I wasn t too concerned about it: the sand would
get to be an inch or two high in my room. My roommates, who were
meticulous, would come in and say, "What the blazes is going on
here?" One guy got so upset about it, he d come in with his own
vacuum and he d vacuum my room! I found this amusing; he did not.
So the sand storms were very
Can you vacuum up the sand?
Yes. Then you d pour it outside,
interesting.
Could it come into the hospital?
Oh, it came everywhere. It did. Of course, the hospital had a
little better AC--the new hospital. The old hospital? Well, when
the sand storms were on, you knew they were on. We used to keep
the blinds down, everything, to keep the damn sand out. But you
couldn t keep it out; it was very fine; and of course when you
opened a door, it would blow in. In the hospital, we had big
vacuums. You know, we d run around with those damn things and try
to suck it all up. When the shamals were on, the sand was there.
The operating room?
The operating rooms were super insulated with double doors, triple
doors, whatever--! ve forgotten. It would be stretching it to say
186
that it was a problem. There would be a little in there because
people walk through, but we finally said, "Oh well. Sand never
hurt anybody."
Hicke: Clean sand!
Taylor: But those shamals were something to remember. It was sort of
equivalent to a severe snow storm here. Everybody would get
house-bound and irritable. I think the longest one ever lasted
about a month, and it just wouldn t stop. Everybody got so
touchy, you could barely speak to anybody, because the damn sand
was everywhere.
The New Hospital
Hicke:
Taylor;
Hicke:
Taylor:
Hicke:
You haven t told me about the new building,
something else.
We got off onto
The new building--in those dayswas very modern and very
attractive, as they go there, although Aramco was always against
anything architecturally attractive; it was practical. In fact, I
initiated another new hospital just before I left. It was
amazing, because we had two plans: one of them was an
architecturally beautiful building, very nice, designed by some
big architect from the States; it looked wonderful.
The other was one of these deals where they rebuild around
the old building. And that s what they finally did. I ll never
forget that, because I was on the board of directors at the end,
and we were arguing over this building. The amazing thing was
their approach to it: "Well, you re going to have this beautiful
hospital sitting there right in front of everybody, and we ve got
these old ugly buildings. If we have this beautiful hospital
sitting here, we re going to have to redo these buildings, and
that ll cost us a lot of money." So they turned it down. We
built around the old hospital.
You were on the Aramco Board of Directors?
Just at the end. I finally got on the bottom rung.
What were the problems of moving from the old hospital into the
new one?
Taylor: Well, we kept the old hospital: we kept using it.
went on, that became a health educational center.
As the years
We did all
187
kinds of things over there in the old building: we ran a huge
pregnancy program there for pregnant women, teaching them how to
feed their babies; we had movies on how to change diapers, what a
good diet for the baby was. That was one big part of it; that
went on every day. Our industrial medicine was over there, and
our own public health unit was over there, which was a big
operation for us, for everybody. So we kept using the old
building for very important functions which were not clinical
medicine.
Then part of the time we used it for a place where we put
people who were in medical trouble and couldn t go home. It was
like a holding station. Those would be advanced cancer cases,
some burns that we were working on that were going to take months
to do. I think the OB/GYN delivery unit was the last one to move
from there to the new hospital. So eventually, the new hospital
was basically to take care of, all current, ongoing illnesses,
primarily clinical, and the old building was for preventive
medicine, public health, occupational and health education.
Developing Psychiatric Care
Taylor: The other major area we finally developed there was the first
psych ward. That always amuses me because when we were first
there, we had no psychiatrists, we had no psych ward; we had
essentially very little business and very little interest in it.
But as the years went by, we changed that. When I left, we had a
regular psych ward full of people, and I think it s sort of a
measure of the impact of the times. We had two Arab psychiatrists
and a large inpatient and outpatient service.
Hicke: Since we re talking about that, why don t you tell me how that
developed?
Taylor: Well, it just evolved. It s a sad commentary on the Western
world, I think, because most of our early psych patients were Arab
employees. They came under the same pressures as everybody else:
advancement, promotion, failure to advance, disappointments in the
work sitethings of this sort, and inability to keep up with the
changing times and changing customs that were happening all around
them. And so they had emotional problems. Originally, we had an
American psychiatrist for the Americans. But he would also take
care of the Arabs, most of whom spoke good English. As that crowd
got larger with the increasing pressures of advancement, we
finally got an Arab psychiatrist, because we had not only the
188
employees but their dependents who came inbecause they too were
undergoing major changes in their social structure.
I think the reason that the Arab people, in general, had very
little emotional trouble is because their societal lines are black
and white. They re very clear cut: if you do this, you re on the
right side; if you do that, you re on the wrong side. Whereas in
our society, not only are they blurred, I think they re probably
almost gone: you get to the point where you think, "What can
anybody do that anybody s going to do anything about?" But not
there. If you do this, you re going to get that, so that they
know from the youth on up what s right and what s wrong much more
clearly, and so they have less trouble coping with that problem as
time goes by. So there was not nearly as much need for
psychiatric situations. Plus you have to remember in those days,
there were no schools; they didn t go to school--
Hicke: The Arabs?
Taylor: The Arabs. I m pretty sure it was into the seventies before there
were any girls schools. First they had boys schools; and then
eventually they had girls schools. But even in the schools, the
pressures were not severe; schools were 50 percent religioushalf
the day they taught the Koran, and the other half, they would
teach various and sundry subjects that were germane to what they
were doing there. They didn t have a feeling of pressure; they
weren t trying to get into college. So the kids didn t have the
pressure that our society puts on them.
So the emotional problems were very minimal, comparatively
speaking. I think, rightly, now there are more, for very obvious
reasons. But you still have clear-cut lines of right and wrong,
so there s not as much consternation in the minds of the young
people as to what is acceptable. I think there is less of that
kind of underlying background to cause them to get into emotional
dilemmas. Once they got into the company, and they were trying to
move up, then they got into emotional dilemmas-- just as we do.
Hicke: That s interesting that the work pressure is stronger than say,
inter-sexual relationships and things like that.
Taylor: Oh, that was clear cut. That s why it didn t create problems.
There weren t any inter-sexual problems, at least not that I was
aware of: that was a clear-cut code. And it worked; it was there.
They didn t drink, smoke, and do drugs, which create a lot of our
problems in the rest of the world. The problems which loom so
large here around illegal drugs don t exist there.
189
Accreditation
Hicke: Let me just mention a couple of things. In 1957, the health
center was accredited.
Taylor: Right. That was in the new hospital. Obviously, I was there
then. It was in the new hospital, because I ran that
accreditation for the first time. There was probably a
misconception in a way about accreditation, because accreditation,
oddly enough, has very little to do with the quality of medical
care; whereas it has a lot to do with the safety of the building,
the environment of the building, the prevention of cross
contamination amongst patients. It has a lot to do with the
record keeping; they usually come in and pull twenty surgicals,
twenty medicals at random, and then they ll go through them to see
if the record is done right with physical examination and progress
notes, nurse notes, et cetera. The format of the record was
important, but the attention to actual climical management was not
criticized.
They don t get into "Well, here s a guy with TB of the
kidney. What did you do for him?" They don t get into that.
What they do is they say, "Okay. Here s a guy with TB of the
kidney. You took his history and physical [examination]; you
established the diagnosis; you kept progress notes on him. The
record is a good record." We had opened up some extra isolation
places, and that air-conditioning was not isolated from the rest
of the hospital; so they said, "We will not approve until that s
corrected." As a matter of fact, I will take the blame for that,
because we hadn t thought about this cross contamination in the
air-conditioning when these new places were opened. So we closed
them down and fixed the problem, and we were approved. But that s
the kind of thing they were more interested in--fire hazards,
smoke detectors, hoses, all these things; they d pull them out; do
they work? The accrediting is very concerned about the physical
plant. For example, we had to have an emergency generator.
They d go around and flip it on. And it if it doesn t work, you
don t get approved.
Secondly, they are concerned about the quality of the chart
itself, but not about the medical care. That s a big
misconception. Because people say, "Mass General [Massachusetts
General Hospital] is accredited. It must have great medical
care." That s not true. What it means is "Mass General is a
great medical plant. It has a great facility." Now, at the same
time, if you do keep your records well and you do have everything
in, it does promote good medical care, obviously. But nobody
comes around and says, "Hey! This surgeon isn t seeing his
190
patients post-op. How come?" That didn t happen. That doesn t
happen today, either.
Hicke: How did you go about getting the accreditation?
Taylor: I had been in accreditations back here to begin with, so I knew
what they were about. And they send you exactly what you have to
do.
Hicke: Do you request it?
Taylor: Oh yes, you have to request it, and you have to pay for it.
They d bring a whole team over. Originally, it was four;
eventually, it got to be ten.
**
Taylor: In general, in the intervening times, we kept things up to
accreditation levels, because once you were accredited and you re
claiming that you were accredited, you should function at that
level; and we did. Accreditation is an ongoing process, and once
achieved, no one wants to lose it.
Hicke: How often did you have to get inspected?
Taylor: I think it was a two-year interval, unless you were on probation;
if you were on probation, it could be as short as six months.
They d say, "Okay"--like this air-conditioning thing that was
found in June--"we ll be back in January to confirm that this is
approved and then you ll get your reaccreditation. " So I think it
was two-year intervals, and then if there was anything amiss,
they d tell you what it was and give you so long to fix it. If
you didn t fix it, then you lost your accreditation.
Those were always stressful, because everybody had to run
around and make sure everything was up to snuff--that all the
physical plant operations were right, and that all of the records
were complete. The records, in general, were well maintained.
Now, the records were what separated us from the rest of the
medical centers in the Mideast, because record-keeping in most of
the world is a very marginal effort. As the years have gone by,
precise record-keeping has become increasingly important.
Hicke: You re talking about medical records?
Taylor: Medical only. So if you go into--as I did--go into a hospital,
oh, we ll say in Iraqwhere we wentyou would be very hard
pressed to figure out what s happening to the patient by looking
at the record. So that s a bad thing. England is very good at
191
records; they re the only country that has decent records. Ditto
for Canada. The rest of the world just doesn t think that the
records are that critical, and doctors are somewhat negligent
about maintaining records. They don t like to do paperwork, and
they just ignore it if they can. The nurse s notes also count,
because you want to know what happened, and often the mandatory
notes by nurses tell the real story.
So we kept very good recordsnot only there, but in the
outpatient clinic. At one point in time, we were regarded as the
largest, well-organized outpatient clinic in the world. That
meant just what I m saying: when people came, you knew you could
review their record and see what happened. We were seeing over
two thousand people a day in these clinics. It was a big step,
because we had far-flung clinics all over that Eastern Province,
as the area was called. We saw all these people I was talking
about, plus the local people who would come into those clinics.
And each and every one of them was identified and had a record-
retrievable, and kept in proper sequence, filed properly. It was
all part of the system.
Hicke: And no computer!
Taylor: No computer in those days, but excellent handwritten records were
always available. Whereas if you go into many non-American areas
and you say, "So this patient was here last month; let s see what
happened," there s no way you ll find out. You might ask him, and
he might not know. That s one of the criteria of accreditation,
record-keeping, that separates good American medicine from others,
in that you know what has happened to people and you can maintain
some continuity. TB is a big problem: you have to know what drugs
they re on, how much they re getting, how long they ve been on
them, and whether they actually are- -this kind of thing.
Otherwise it s very difficult to do your job right. We did do
that very well in Aramco.
We were a very organized system. In other words, the doctors
were all employed by us; all the doctors had to work to a certain
standard; we were constantly doing peer review on everybody; there
were no outside doctors who came in on an occasional visit basis--
none of that. It was all a very controlled system. So we even
got high marks on that. If you go down to our hospital here,
there ll be guys who come in and see a patient once a month, and
they may or may not fill out the records, and the poor records
people are chasing them all the time: "Please fill out these
records." And they may be three to six months old or may never
get filled out. We didn t have any of that. That was one of the
key things, and that, we did well.
192
They were big on the lab. We had a very good lab. Good
blood bank; the only blood bank in Arabia at that time.
Hicke: Did you collect it yourself?
Taylor: We had a whole blood bank system, where we d collect the blood and
have blood on tap for operations and major bleeding problems. It
wasn t easy. There was great resistance to donating blood, as
there is in most countries. They didn t like to donate blood. It
was understandable. They just couldn t visualize why we thought
they should give their blood to somebody, particularly somebody
else who wasn t related or close to them. In fact, most of the
blood was donated by Americans who were conditioned from World War
II about giving blood.
Hicke: Did the government give any help on that?
Taylor: Not on that. They had their own problems, which were worse than
ours: trying to get it in their own hospitals. It was just
practically impossible to force anybody to give blood. It s just
an impossibility. There was a long, historical background in that
society that being bled was not a healthy thing. It was very hard
to overcome. But we did have a reliable blood bank, and we had
very up-to-date cross-matching techniques; we didn t give the
wrong blood to the wrong people. So the lab, the blood bank, the
x-ray unitwhich was very modernthey were all good. In other
words, the supporting services to the clinical medicine were
strong. That s what makes good medicine.
We tried to keep up in these areas, although I remember when
we wanted a CAT scan operation, that was hard to get. Whenever we
went up to management with a major expense item, which I would
usually present, it was often amazing to me how difficult it was
to sell it. They ve done it since I left; but when I was there, I
was still trying to get this CAT scan in. I must have been
ineffective.
Hicke: How much did they cost?
Taylor: At that time, that unit was going to cost $600,000. Back in the
late sixties-early seventies, Aramco management would think, "Gee,
that s a lot of money," you know. And their question was, "Do you
really need it? What can you do with that that you can t do now?
How much good is it going to be?" And in the old days of CAT
scanning, when it was still a little bit dubious --"What can the
damn thing do?"--you could be hard pressed, as I was, to prove to
them that you had to have this sort of thing.
193
It was interesting, because we had the same sort of thing
when it came to computerizing. In my last years out there, there
was a big push on to computerize the hospital. We partially
computerized it. This was my decision right along. Being
computerized has obvious advantages to it. The big problem with
us was when it would go down. For example, they wanted to put all
the drug system on computer, which they do in many hospitals now.
If you re on a ward, the computer will say, "Send up six shots of
penicillin to ward six for these numbered patients, and each one
of them gets the shot at four o clock this afternoon." And that
comes up on a tray and the nurse gives them. So it s all done by
computer; you ordered it by computer, it comes back by computer.
Well, I wouldn t do that.
The other thing they wanted to do, which fascinated me, was
to put in a computerized delivery system: it s like a little train
that fits in the walls and that would take drugs, food, messages
to various destinations. They have that in many places. In the
pharmacy they just put them on in the proper sequence, and then
they would go around to the various wards and they would get
offloaded. Well, that s great until it breaks down. Because in
this case we have two things to break down: the train itself and
the computer. And we were already having trouble in other parts
of the company with the computers. When they d break down, it was
a helluva job to get them fixed. When the King Faisal Hospital
went on with computers, they finally had to hire a twenty-four
hour team from Japan to maintain the computer. Sony. Because if
it once goes down, the hospitallike the King Faisal Hospital
which I consulted on to get it in operationif a computer goes
down, the system fails, chaos reigns. So if the drug system goes
down, there s nobody to get the drugs from the pharmacy to the
ward, the food from the kitchen to the patients, et cetera; the
hospital doesn t function.
It becomes chaoticwhich they found out the hard way. The
lab was on the computer, and the lab computer goes down. The
whole system breaks apart, because you order by computer; once you
can t order by computer, and you have to go back to the old
handwritten delivery system, why, you have a serious problem. As
a result, in Aramco we only computerized in a modest degree. And
I m sure since I left, they ve probably updated that and have a
fully computerized system by now.
Hicke: It s probably much more reliable by now.
Taylor: It s more reliable, as they now have what we call a mainframe
system, because Aramco is totally computerized. They have a home
team out there, employees who are computer experts, so they can
come down and keep the computers running. And they have the parts
19A
Hicke:
Taylor:
in store and this kind of support, which we didn t have
originally. We had to fly them in. So that was a problem. But
now, I think--! haven t been backbut I suspect it s fully
computerized at this point in time it should be. They ve got the
money and they should do it. That s how that evolved.
Well, we were just on accreditation business,
that?
Can you finish
Accreditation became a way of life. The funny thing about
accreditation is that once you re accredited, it s very
uncomfortable to back out of accreditation. And occasionally, you
think, "What good is accreditation? I mean, we know we re running
a good outfit." The good, I guess, is, like every year when we d
get accredited, it would come out in the local paper that we were
re-accredited, and everybody would breathe easier thinking, "Well,
we have a great medical system because we ve been reaccredited by
the joint commission." It had a good public relations impact.
The problem was the part that people failed to realize a
hospital may be accredited, but it may not be doing good medicine.
That s what people don t know, because they automatically think,
"If it s accredited, it must be doing great medicine. It must be
medically up to certain standards." That s true. I m not against
it, because it certainly is an incentive to do medicine right. In
other words, it s better to be accredited and at least kept to
that level, than not to be accredited and work at some lower
level. So we kept doing it, and they are still getting accredited
as far as I know. It became an established thing, and as far as I
know, it still is. Being accredited is definitely a positive
factor in having a medical system.
Medical Training
Hicke:
Taylor:
Let me ask you a little about teaching duties,
had some teaching duties all along?
You indicated you
Hicke:
Yes. We became accredited by the Royal College of Surgeons, which
is somewhat equivalent to the American Board of Surgeons in the
U.S. After this, surgeons who worked in the Aramco surgical
system could get a year of credit towards being a fellow in the
British College of Surgeons.
When was this?
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Taylor: This was in 1961. That was a representative from the Royal
College, Dr. H. Wells, who was there to accredit us. He came down
and went over our system, came in and watched us operate, and
actually operated with us. He spent, I think, a couple of weeks
there to approve us, our training; and we were approved, so that
people who worked with us could get time credit for becoming a
member of the Royal Academy of Surgeons. And several did become
members. They had to go to Englandusually London. We were good
for the first two years, but after that they had, at some point in
time, to go up and do two more years sometimes more than that to
finally get to be a Royal College-accredited surgeon. This was
good for us, because it kept us on our toes. Every two years we
had to get reaccredited by the R.C. of S.
When they developed a medical school in Riyadh, some of the
students would come over and work with us as interns. That was
probably around 1970, I would guess, thinking back. So we trained
those people. And then we trained our own people, extensively.
We had training for lab, x-ray, all kinds of technical support.
When we got new doctors in, we trained them. When we hired a new
doctor, they had to go through a year of training; they had to go
through their first year being closely under a supervisor who was
making sure that they did things "our way," so to speak. There
was no medical school in our area then. There may be now. In
fact, it was in the wind when I left, that there d be a medical
school in Damman. So if that s there, I m sure that they will use
the SAMSO hospital as a training center. But that was after my
time, so I don t know. When I was there, we did the necessary
training to guarantee quality of care.
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IV CAREER DEVELOPMENT AND RESPONSIBILITIES
Chief Surgeon, 1961-1963; Hiring Staff and Relationships With
Management
Hicke: Okay, let s go back to your career a little bit. You became chief
surgeon in 61? What kinds of responsibilities did that mean?
Taylor: Before that, I was the assistant chief surgeon [1953-1961]. Dr.
Lonas resigned, and then I became the chief surgeon. As the chief
surgeon, you were over all the surgical services, not just general
surgery. OB/GYN, orthopedics, urology, whatever surgical activity
was done was under the chief surgeon. This was an interesting
little phase of development, because Aramco management was slow to
accept progress in these areas. This was very disconcerting,
because one of the things that has always amazed me in lifeit
shouldn t, but it doeswas how some of my most intelligent
friends have a paucity of knowledge about medical people and what
they can do. And a lot of people would say to me, "Well, you re a
surgeon." And you were considered to be competent in all fields
of surgery.
But American management, coming from the old daysWorld War
II, when the surgeon is out there doing all kinds of stuff --had
this vision of the general surgeon being able to do all these
things. As a matter of fact, we were occasionally doing things
that were beyond our scope. I used to do severe head injuries,
and operate on brains and skulls that were caved in and things
like this. This was very complicated surgery. We did a pretty
good job under the circumstances, but as far as doing it as well
as a neurosurgeon that didn t happen. For unknown reasons,
management was extremely resistant to appropriate progress in the
Medical Department. This was penny-wise, pound-foolish management
by Aramco and should have been changed long before it was.
Hicke: Did you feel you wanted to hire different specialists?
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Taylor: The first specialist we finally got was an orthopedic surgeon, Dr.
Charles Thomas. I d been there long enough that I usually knew
the top level managers. Every president after Hardy was a good
friend of mine. We were good friends; and I d say to them, "I
cannot understand your approach to this when you may get hit in a
car next week, or your wife, or your kids, and have bones broken,
and we ll have guys down there fixing them, including me, who
aren t nearly as good as an orthopedic surgeon." It was just
beyond me, because, between us, there was never a true money
problem. What a joke Aramco didn t have enough money to hire a
good medical staff!
Later we did have a chest surgeon who was a general surgeon
and specialized in chest. But it was just like pulling teeth.
You d go up time after time, and some of these upper-echelon
managers who were resistant to this would say, "Well, we ve gotten
along without them. Were there any major problems because we
didn t have them?" Well, the true answer was "Yes"! [laughter]
But luckily, I guess, for everybody, it wasn t very often. So
that was one of my most difficult tasks, one of the most difficult
to accomplish.
Hicke: Not all of them, but most of the presidents and CEO s felt the
same way?
Taylor: Well they seemed to.
They don t think about it until they re sitting at the table
and I say, "I want to hire an orthopedic surgeon. He s going to
cost so much money. We need him."
And they d say, "Well, how come we need him now?" And then,
"We never had one up until now, you know."
"Well, the world is changing."
There was a day, back in World War II, at Mass General, when
orthopedic surgery was done by general surgeons. They weren t
really specialized as orthopedic surgeons. But that went by; we
didn t go by with it very easily. I think it was one of these
decisions where they saw it as sort of a major change and were
just resistant to the decision. And after I d leave, they d
probably say, "Well, old Taylor is up here pushing to get this.
We ll put that off for a while and see how things go." And it
gets turned down again.
When I left, we finally had gotten a good orthopedic surgeon.
We had a good chest surgeon. And that was their attitude: "We re
getting along okay. What s the problem?" There were a couple of
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bad accidents amongst what we called in those days the senior
staff, and that helped push that along. Because I made no bones
about it: if we don t have the right guy, we are going to have
major setbacks in the specialty fields, much to the sorrow of
those involved.
It was a bad decision on their part, as far as I m concerned.
Now they might say, "We saved three million dollars over the years
by not doing it." But they really didn t: they had general
surgeons doing it, who weren t as good, and they wouldn t have
paid the specialists any more than the general surgeons. Now for
neurosurgery, for example, they said, "How many neurosurgical
problems would this guy see? Would he be fully employed? Would
he be working?" "Well," I said, "I don t know about that. But
let s look at it generally. Suppose there s one that comes up
tomorrow: a guy comes in with his head mashed in, and we can save
his life and return him to normal. And that may be his only big
case of the week. Maybe you only do fifty of those a year. No,
he s not working on a big case every day." That was an
interesting decision on Aramco management s part. This slowed
down the progress that should have been made.
Hicke: Quantity is not really the issue, is what you re saying?
Taylor: That was hard to do, and that remained hard to do throughout my
entire time there. It was hard to keep the system moving with the
times, which I could never understand. I just couldn t understand
it. Bob Brougham was one of my real solid friends; I finally
convinced him. I said to him, "I ll tell you something
interesting. The thing that people will remember and appreciate
most about Aramco is the health care. The money is okay, but when
somebody comes in really sick or really hurtthey have something
wrong with them- -and they get good medical care, they remember
that. I think if you take a poll of all the Arab employees and
say, What about Aramco do you like best? 1 you d get 99 percent
saying the medical services. And not only that, but we take care
of all these other Arabs, including the royal family who come to
us all the time. Now what better way to befriend the country?"
I said, "I just can t believe that they don t think it s a
great benefit to them, and that Aramco is a good citizen because
they re providing these kinds of services. If you eliminate
medical services, I think there d be a very unpleasant reaction to
that." Management often would say, "Let s tone down the medical
services." As I was telling you originally, they used to accuse
me: "You re building a medical empire!" Which I was, because it
should have been done. I told Brougham, I said, "It s easy to
afford it. It s a worthwhile goal. Because the way we re doing
is too slow and cost-conservative. We re not out here building a
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Mayo Clinic. But we want to be working at a certain quality
level, and we sometimes do not measure up to the quality Aramco
should provide."
So you were mentioning in there [in the outline], "What was
the relationship between the Aramco administration and medical?"
It was not what it should be. Aramco was not concerned enough
about providing the proper quality of care.
Then on top of that, of course, the Aramco administration was
always caught between the parent companies and the field. The
parent companies were surprisingly resistant--"It s a business.
The bottom line is what counts. Whatever is going to cost a lot
of money, we re going to be against, unless it is in concrete that
it must be there." So, our people were a little reluctant to
bring up, say, the CAT scanner for a million bucks or whatever it
was, because some guy from the parent company was going to say,
"What the hell do you guys need a CAT scanner for out there in the
desert?" After all, the chances of them needing it for the few
days they were in the fieldthat was another resistance factor
that weighed heavily on management. In general, most of them
would hate to go to the parent company gunners who came out once
or twice a year and say, "We need this for medical." Because it
was just another request for something else, and the parent
company guys disliked additional requests for expensive "luxuries"
in the field, even though Aramco literally carried them when oil
financial pressures had the stateside companies in the red.
Hicke: But, you know, I think you really had a major influence here,
because not only did you have this marvelous health center in
Saudi Arabia, I don t think there are very many oil companies that
have this kind of offshore medical facility.
Taylor: Not of that scope. This was and still is, as a matter of fact,
as far as I knowthe largest American overseas group in the
world. At their peak, there were approximately 8,000 Americans.
Now I think there are about 4,000. They were guaranteed, and it
was written in their agreement, that we d provide good medical
care. And somebody would say, "What is good medical care?" We
would never say Mass. General; we would say it s as good as the
average small- town hospital. That was our goal, and I think we
met that goal.
I told people, including the doctors that I hired: "You are
taking a certain risk, medically, when you go to Saudi Arabia. If
you get into an automobile accident and get major injuries, your
chances of doing well are certainly not as good as they are where
there s a neurosurgeon. " You d think anybody would recognize
that, but--. I had people turn down employment over there because
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of medical, particularly if they had any kids or somebody with
major medical problems. We had no facilities for the disabled
like deaf, partially blind, autistic, or some of these things that
need ongoing, persistent care. In fact, we would turn down
employees who had those kinds of problems, because we knew they
wouldn t be able to get along properly without that out there.
We never aspired to be a Mass. General; that was too much for
us. We had a rule, which I suspect is still there, a regulation,
that any employeeother than the Saudiscould be returned to his
country of origin for medical care if it was necessary. And of
course, the employees knew this. Now, the question that would
come up was: "What is necessary and what is not necessary?"
Medical management made that decision. Let s say that an employee
had multiple sclerosis, for example; this was one of many such
problems. He would say, "Well, I have to go home to have this
treated." We would usually arrange to have that done in
connection with a vacation, assuming it s not an acute episode at
the moment. Chronic problems that could be handled in connection
with vacation were usually done that way.
Then we would get the results back, after a workup at some
multiple sclerosis center; we usually went to the New York
Neurological Center. They would send back a whole program for
this employee, which we could follow. Now if we couldn t follow
it, if it was too complex for us, then we d have to say to that
person, "Well, you can t stay here, because we re not going to
send you home every month to get this thing taken care of. We
can t be certain your medical problem will get the care you need,
so you will have to return to the U.S.A."
Now let s say somebody turned up with a cancer of the breast,
and they needed not only surgery, which we could do there, but
they needed x-ray therapy and chemotherapy following the surgery.
Then, we d usually give that patient the choice: you can either
have us do part of it and then get additional care in your country
or return home and have the entire problem taken care of. Usually
patients chose to go home.
I*
Hicke: We ve just been talking about your period as chief surgeon from
61 to "63. Was there anything particularly memorable that
happened in those two years?
201
First Open-Heart Surgery at Ar amc o
Taylor: Well, I did the first open-heart surgery there, which was
interesting, as much less major surgery had been the rule. Arabs
had to make do with what we could provide. Neither Aramco nor the
government would send them out of the country, as this was their
country. Consequently, in some instances we were doing procedures
that were a little beyond what we were set up to do. I decided
that since there were some serious heart cases around and these
patients had serious trouble and were going to die if they didn t
have something done, we would see how that went. So I did the
first mitral valvotomy, which is a simple, open-heart procedure.
It went okay, but it was a major challenge.
One, you need a lot of blood for these procedures and we
didn t have a lot of blood. To set up six pints of blood for a
procedure was a big deal with us, because it was just hard to get.
Secondly, the surgery is simple, but the support that s required
to go with big surgery is essential to success. You have to have
the right anesthesia. Looking further, you have to have the right
equipment to go with open-heart surgery. Further, you must have
the right technical people around. We didn t have that. Then
what you have to decide is, "Well, is this patient better off
taking the risk going with us, or is he better off just going as
long as he can without anything?" A very difficult call to make.
Temporarily, we decided against major heart and vascular surgery.
We really couldn t do it right.
Luckily, the thing got turned around and we could get the
Saudi Arabs out for highly specialized procedures. So we didn t
have to worry about it anymore. We quit doing surgery which was
too big for us. Secondly, the King Faisal Hospital was completed,
plus great strides were made in the medical care that the Saudis
delivered in other parts of the country, and so they began doing
these complicated procedures under Saudi auspices, and it s my
understanding they now do them properly.
Hicke: This was in the seventies?
Taylor: Yes.
First Lung Removal
Taylor: I also did the first pneumonectomy, the first lung removal, which
was another thing that hadn t been done.
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Hicke: Tell me about that.
Taylor: This was a patient with his left lung destroyed by TB.
Tuberculosis now rarely requires major lung surgery, but it did
then. If diseased lung tissue was not removed, the disease would
continue to spread and kill the patient.
There was a lot of TB in Arabia; and even today, I think that
TB is the most difficult medical problem Saudi Arabia has to cope
with. When Aramco was in the early years, malaria was the major
medical problem, but the Preventive Medicine Department under Dick
Daggy eliminated malaria in the Eastern Provincea major medical
triumph, quite possibly the most important accomplishment of the
Aramco Medical Department.
Dr. Daggy probably did more for Arabia healthwise than
anybody else, even though he s not a [medical] doctor. He s a
Ph.D. and he later become medical director. But that [eliminating
malaria) was a major accomplishment.
Evacuation Procedures
Taylor: In the medical business in the seventies, we were trying to
delineate how far we should go. With the Americans, if a guy had
medical problems beyond our scope, except for acute emergency,
we d send him back to the States. I had identified centers for
their specialty expertise; so if a patient had a cancer, we might
send him to M.D. Anderson in Texas, one of the highly specialized
cancer centers. Or we might send him to Mass General here in
Boston. Heart problems would be sent to the Cleveland Clinic,
which was the original coronary bypass center. And so on and so
forth. Of course, air transportation became much better: it used
to take us three days to get by air from there to here; later on,
when we had our own plane, we could fly a patient back in less
than twenty-four hours.
Another thing that we did that was kind of interesting: we
coordinated with KLM [airlines] and we designed and implemented a
hospital evacuation setup in KLM jets, which took up eight first-
class passenger seats. We had this unit, which they kept, and
they evacuated people all over the world with our unit. But
whenever we needed it, they would come and pick up a patient.
This area in the plane was converted to something like a small
intensive care unit: we had IVs, EKGs, and oxygen and all kinds of
equipment in it; a medical bed that fit over the first-class
seats; and an area for nurses. It was a highly specialized unit
203
which we developed and improved to evacuate patients over long
distances to world medical centers.
We used KLM on many occasions to get acutely ill patients
back to the U.S., usually to New York City. That was the nearest
place that had multiple major medical centers. We used
Presbyterian Hospital, particularly for neurosurgical problems and
major orthopedic problems and things of that sort. That was very
useful to us for quite a while and obviously a must for patients
who needed highly specialized care.
Then when we got our own jet planes, we d use them. But they
weren t as good as KLM, because they were small; these were
Gulf streams with limited space. But you could certainly transport
a patient quickly, as we had to wait for KLM. In those days,
these evacuation units were on the big jets, these were on DC-8 s,
plus a part of the agreement was they would come at our request.
Because if you had to wait for a scheduled flight in the early
days, that might be two days later, and that might be too late.
So that was our method of evacuation for the intervening years and
saved several lives.
Contract HospitalsAnother Change
Taylor: So that s how things changed. Now the major reason for that was
interesting, because at one time we used the local hospitals for a
lot of our patients, mostly on a postoperative basis. For
example, we d do a hysterectomy, and then after we d done the
hysterectomy, we d send them downtown to the local hospital. This
wasn t a good relations concept; they didn t like that, because it
was an obvious economic decision. The reason was that keeping a
bed down there was about fifty dollars a day, and a bed at our
place was about three hundred dollars a day. That concept was
quickly abandoned for obvious reasons.
Hicke: When you say downtown-
Taylor: That was in Al-Khobar. There were two hospitals down there, run
by local people. Joseph Yamine was one of them, director of the
Asharq Hospital. Moh d Ali Ahmed was the other Lebanese running
the Asalama Hospital. They provided a service which was expensive
but good; so that the local people, many of whom had the money,
had a place to go. They had good doctors down there, oddly
enough, because they paid wellbetter than Aramco. They were
from the Middle East and did good work.
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Hicke: We re talking about the seventies?
Taylor: Yes. Late sixties, seventieswhen government health care was
still in the developmental phase; they hadn t really gotten into
local medicine yet. We would use them as part of our system.
Sometimes it was odd, because speaking of specialists, for
example, they had an outstanding ear, nose, and throat specialist.
So we would send our own patients down there; Americans would go
down there if they had something like a ruptured ear drum that had
to be fixed. We would use them a little bit, but others living
locally would use them a lot.
When the Aramco philosophy changed about what our
responsibility really should be, we decided it should be more
inclusive than what we had been doingwe no longer sent Aramco
patients to Al-Khobar hospitals. This required an increase in our
capacity. We took them all in, and that increased the budget
significantly. I was not necessarily pushing this concept so
much, but management did, because they were getting too much heat
on "we go here" and "they go there"; that was beginning to be a
major relations problem; so this major shift in hospital policy
occurred. And as a result, the budget went up--way up.
Attractions of Life With Aramco
Hicke: Before we continue, tell me what you were just telling me off tape
about why you stayed so long. Do you want to put that on tape?
Taylor: Well, I don t mind. Number one, I had the right personality for
Arabia: I m adventuresome; I like excitement; I like to do things;
I like to meet exciting people. For example, I took care of the
whole Kennedy family, starting with Ted Kennedy, for a week. We
had all kinds of unusual surgery. At one point, Secretary Vance
was there, Cyrus Vance. Another time we had to bring in the
secretary of State under Eisenhower, Dulles, for a medical reason,
as explained below.
Just a quick vignette: we had an employee who accidentally
killed an Arab. It was a sad situation, because he was driving
through Al-Khobar very slowly and carefully, and an older, blind
Arab citizen just walked right out in front of his car. He d
barely hit him, but he hit him just enough to knock the man over;
so the man fell, hit his head, and died. The rule was, under
these circumstances, that the American system had to make a
decision: they could either deport that person immediately, so
that the employee did not get into the Arab judicial systembut
205
it had to be done before midnight. So the involved person had
that choice, along with Aramco. If the employee decided to take
his chances in the local court, he could. But whatever the
decision was, that was it. The local people, and I think with
justification, would say, "You come to the local court, you must
accept the ruling of the local court." This employee, thinking he
would win, chose the local court and lost.
So they put him in prison. Nobody ever knew for how long.
And going to prison in Saudi Arabia is a dangerous thing to do.
So he got very sick, and to make a long story short, if he stayed
in prison, he was going to die. There was no question about it.
He was dying. So I told Aramco, "If that employee remains in
jail, he s going to die." We were seeing him regularly and he d
gotten very bad liver trouble and was deteriorating. So Aramco
wanted him out. And so did the royal family; they didn t want
some American dying in jail under these circumstances.
But the local governor, Amir Ibn Jaluwi, was a very tough
person. I knew him well. Once Amir Ibn Jaluwi, who was almost
the original king, made such a decision, nothing could make him
change it. Aramco got John Foster Dulles to come to Saudi Arabia
to see the king. The king had to get Dulles and Ibn Jaluwi
together; and when they got together, there was a major conflict,
because Ibn Jaluwi didn t take anything from anybody, including
the king. Eventually, some major concessions were made to Ibn
Jaluwi that he wanted, and the patient was released. We flew him
out. And he survived. I wasn t sure that he was going to make
it, even if he did get out. But it just shows you how stringent
it was and how difficult it was if you took your chances like
that. Very few people ever did that, for obvious reasons.
Hicke: After that, I can believe it.
We were starting to talk about your becoming chief of staff,
but I wanted you to tell me why you chose to stay.
Taylor: Those were the kinds of things that kept me around. I enjoyed
those kinds of things. As a matter of fact, as I was saying
earlier, when you become an expatriate, you really became an
expatriate; so all your friends, all your activities, were
associated with Aramco. You are separted from U.S. living, and
it s a whole new way of life.
I was athletically inclined, and Aramco provided that. They
had all kinds of sports events; they had everything you could
think of. I was a tennis player of some skill, and I was the
Middle East tennis champion for several years. My wife also
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played well. We were number one, both of us, in the Middle East.
That was a big attraction for us.
Hicke: I recently interviewed Richard Perrine, and he told me to ask you
about playing tennis at lunch. For some reason, he said you d
drag him out there and play tennis at lunch.
Taylor: Well, I was number one; and in those days, I was heat resistant.
Dick was a very good tennis player, and he would challenge me. If
you were challenged, you had the choice of time and place. And so
whenever I thought it was going to be tough to win, I d say,
"We re going to play at noon!" Everybody else wanted to play
either early or late, but I thought Dick was good enough, so it
had be at noon: "Dick, I ll meet you at twelve o clock down at the
courts . "
So I had a great time out there. I ll tell you something: if
I had it to do over again, I d do it. When I talk to some of my
friends that were here, surgeons, they ve had a boring life, as
far as I m concerned. One thing I will say about Arabia, which I
consider to be very important: it was never boring.
Hicke: That could be the good news and the bad news.
Taylor: In any event, it was an exciting life, and we met many interesting
people. We traveled all over the world, which we enjoyed. Our
children were born there and grew up there. Both of them were
very prominent in the local scene as kids.
I think that the big dilemma with people was when to leave.
Aramco, as I said before, had a backloaded system, and there were
significant financial benefits for those who stayed.
Hicke: You did say that, but you didn t tell me on tape.
Taylor: Originallywhich was common everywhere- -with regard to things
like your retirement, you had to stay so long. Originally you had
to stay twenty-five years to get a retirement. If you didn t stay
for twenty-five years, you didn t get any retirement. So
obviously, people were very determined to stay twenty-five years.
The employee who killed the Arab, had he left, he would have had
to sacrifice his retirement. And he d been there eighteen years
or something like that.
Hicke: So that explains it.
Taylor: So that was why he was so determined to do it. It wasn t that he
was obstinate; he just hated to give up a life s work, his
retirement. Then later, it became modified as it has in the
207
States. Now it s portable: you can retire anytime, and you can
take along whatever you ve got put aside thus far.
But originally, they kept backloading, so that the longer you
stayedand the magic number was twenty-five when I left in
twenty- five years, you got all Aramco had to offer. And in a
sense, you didn t get much more after that; you kept it, but it
didn t keep going upwhich they did on purpose because at that
time, they wanted you to leave. [laughter]
Hicke: Why was that?
Taylor: It was a very interesting thing: originaly at the age of sixty,
you had to leave and I mean had to leave. They had it so
arranged that nobody if they could possibly avoid it, and that
was most of the time could be in Arabia sixty plus one days. So
you had to leave when you were sixty, on your birthday, or before.
You could leave or retire before. But they just had this funny
rule that sixty is it. Sometimes the guy would leave, and his
wife and kids would still be there packing up! [laughter] I
always thought, "Boy, talk about holding the line!"
Hicke: Why? Why did they have this?
Taylor: The reason was many people didn t want to leave, you see. The
employees were always trying to figure out some way to stay a
little longer and hang around. A lot of people thought that was
their world and their life, and so they hated to leave. In fact,
some of them actually retired in Saudi Arabia- -but not many; I
think maybe five out of the whole crowd. But people just kind of
hated to go. So they finally made a rule: on your sixtieth
birthday, you re either leaving that day or before, and that s it
--and there are no more arguments. One of the guys said, "July
the sixth is my sixtieth. I gotta be out here on July the
fourth." So that s the way that works. As a matter of fact,
Perrine, the guy you talked to, was the first employee in Aramco
history, after the law changed, who stayed after sixty. It caused
a furor. He wouldn t go, and because of the new law he stayed on
for two years .
Hicke: He didn t want to go, either; I recall he wanted to finish up his
research and publications.
Taylor: It s crazy. You wonder, "Why would anybody want to stay in this
crazy world?" It was something. But it was an exciting life.
There was a social life out there you couldn t believe. And the
social life was fast and furious inside this litt
