The merciful aftermath of the Moroccan oil tragedy
Ten thousand men, women and children, paralyzed by poisoned cooking oil in 1959, might have ended their lives as cripples. Now doctors can report that all but a handful are walking and working again. This is how an international medical team led by Canadians carried out an historic exercise in the salvage of human beings
THE MOST DEVASTATING MEDICAL STORY of our time began with what looked, at first glance, like a polio epidemic. In late August of 1959, in the ancient Moroccan city of Meknès, people began to report a mystifying paralysis of the feet, hands, and sometimes legs. But tests soon showed it could not be polio. The roll of the stricken grew at a rate as terrifying as the disease; by mid-September there were three hundred new cases every day in Meknès. Reports of similar, if smaller, outbreaks began to come in from other parts of Morocco. Could it be a previously unreported strain of virus? The Moroccan health authorities asked for outside aid. From Oxford, England, the World Health Organization of the United Nations dispatched two epidemiologists. Drs. J. M. K. Spalding and Honor Smith.
Presented simply with the number of cases and the rate at which they were being discovered, the British team was at first inclined to agree with the virus theory. The paralytic symptoms could quite easily be caused by a virus; there was also, quite frequently, some fever accompanying the paralysis — though a virus would not necessarily even have brought fever. But a more careful study of the statistics assembled by the Moroccans indicated that the disease might be what doctors call “toxic,” spread by poison, rather than “infective.” One important clue was that the outbreak seemed to be confined to the Moroccan artisan class—meaning people with jobs but jobs with low pay. Virtually no well-to-do Arabs were gripped by the paralysis, and almost none of the destitute. Not one of Morocco's two hundred thousand Jews was afflicted, and the only European in Meknès who had been struck down was a man who had adopted the Arab way of life.
The British team made a fairly obvious deduction: that the source was in some sort of food. Jews. Christians and Arabs all eat differently in Morocco.
More careful study of the figures yielded more specific information. No infants young enough to be breast-fed had been reported among the victims. Among the adults, women were in the majority. At the Meknès jail, no prisoners were ill with what the doctors were now calling maladie de Meknès. ln a local contingent of a hundred soldiers only two were suffering—and they were the only two who ate
meals away from the barracks. Most striking of all: among the two hundred and fifty Moslems who had visited Meknès for four days early in September for the feast of the Birth of the Prophet, there were no victims. All had carried their own food.
The British doctors began their search for a poison. They analysed samples of flour. In some they found traces of arsenic, but not enough to cause paralysis. (Moroccans believe a little arsenic in their bread increases virility.) At this point, a Meknès doctor's advice turned the researchers' attention toward cooking oil. He himself had recently noticed some samples of cooking oil—mostly olive oil, used in Arab countries more commonly than butter or margarine is used in North America—that were “as dark as motor oil.” Further, he knew of a family that, suspicious of the dark oil, had given some to their dog. When the dog appeared to be all right, they had put the oil into regular use. In a few days, all had been struck by the strange malady—and so had the dog.
THE VILLAIN OF THE MEDINA
If cooking oil were the culprit, reasoned Drs. Spalding and Smith, it would fit the statistical evidence. Well-to-do Moroccans can afford the best brands, and might be spared a disease spread by cheaper types. Europeans use less oil than Arabs, and what they do use is of the better brands. Jews buy all their food from their own rigidly controlled markets. The very poor can rarely afford any oil at all. Women, doing most of the cooking and eating most of their meals at home, would be worst affected by polluted cooking oil. And if only one brand, or only a few, were polluted, immunity of prisoners and soldiers would be explained.
One of the worst epidemic areas in Meknès was the old Arab quarter of the Medina. With a group of Moroccan officials. Drs. Spalding and Smith began a search of stores in the centre of this area. In the first they visited, they found a single colored bottle labeled Le Cerf, a brand of cooking oil. It was three-quarters full of an unusually dark oil. All other bottles in the shop, and, on that day. in the shops near it. were of colorless glass and contained regular yellow cooking oil. The dark oil was immediately shipped to the Institute of Hygiene at Rabat. With-
in hours, chemical
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In 1930 TCP poisoned over 14,000 Americans
analysis had spotted the poison: a yellow, odorless chemical named tri-ortho-cresyl phosphate, one of the family of oils commercially called TCP in North America.
TCP is good for engines. Mixed with gasoline it helps prevent the formation of hot lead deposits on the cylinders. Mixed with oil for jet engines, it joins with the metal of their roaring interiors—scientists call the action “controlled corrosion”—to form a smooth lubricating surface.
TCP is not good for people. Rubbed on the body, or even inhaled over a long period, it is poisonous. About what would happen to people who drunk it, scarcely anything was known. Before 1959. there had been only two other outbreaks of TCP poisoning, but the literature on them was sparse. The first was in 1930, in the U. S. There, one of the largest bottlers of "ginger jake." a “stomach medicine” made principally of alcohol (this was during prohibition) and extract of Jamaica ginger, found that TCP was a cheap substitute for chemicals used in diluting his product. He began to use it. Before doctors located the TCP in ginger jake. nearly fifteen thousand Americans had suffered varying degrees of partial paralysis and blindness. (Symptoms later described in the Morocco outbeak were often significantly different from those in the ginger jake epidemic, leading authorities to believe that perhaps the TCP was of different types in each, or that other toxic chemicals were involved in one or both.) In 1940. eighty Swiss soldiers were served it meal cooked accidentally with engine oil. Nearly a third of them are still totally disabled.
The mystery of the nerves
In the bottle found in the Medina, there was about thirty-three percent ordinary vegetable oil. The rest was synthetic oil made from animal or vegetable products, capable of withstanding extremely high temperatures and containing TCP.
In spite of monumental advances in recent years, there is still much about the human nervous system that remains unknown.
To varying degrees, and in varying ways, the nerves at the ends of the Moroccan victims’ arms and legs were paralyzed. One common symptom was muscle atrophy in the opponens and flexors of the thumbs; the opponens is the muscle that moves your thumb toward your little finger; the flexor is the one you use to push it against the side of your index finger. But other movements of the thumb were, often, unaffected. Many victims felt as if they'were wearing heavy gloves and socks (again, there is no characteristically unique set of nerves that would transmit this feeling). Others said their hands felt cold, and their hands were cold to the touch. Warm water removed this symptom. Still others suffered what is called “drop foot," a weakness of the ankle that makes the victim's foot flop when he picks it up. a walk the doctors call “steppage gait;" or "drop wrists." which have a comparable affect on action of the hands.
The most severely crippled suffered paralysis of the legs, hips and arms. At first, nearly all the paralysis was of the type called flaccid—the muscles were flabby. Later, some of it was to turn spastic, which is to say the muscles reacted to movement, sometimes by involuntary movement,
sometimes by rigidity. (This change can be explained by describing the “peripheral nerves,” those in the limbs, as a telephone circuit. The switchboard of this circuit is the spinal cord. Apparently the TCP snuffed out both central and peripheral nerves in some of the most severe cases. But damaged pheripheral nerves, if the damage is not complete, can sometimes restore themselves well enough to carry messages. In the TCP poisoning cases, the nerves carrying messages to, for instance, the hands were partially destroyed, and the muscles in the hands were as helpless as discon-
nected telephones. When the lines of transmission were restored, the hands began receiving distorted—spastic—messages from the switchboard.)
Mow had this poison found its way into the cooking oil of Meknès? The source was not difficult to trace. In 1959, the U. S. was preparing to pull some of its air force bases out of Morocco, under agreements reached in 1956 when Moroccan independence from France was settled. In doing so, the USAF sold off many surplus supplies, including some of the TCP-bearing oil they’d used for jets. Some of this oil was
bought by unscrupulous Arab dealers who used it to dilute costlier cooking oil.
By October 2. when the British doctors had established the nature of the poison, the loll topped nine thousand. The Moroccan government was stumped. As a fairly new and underdeveloped nation, Morocco had virtually no facilities for assisting the victims. There were no hospitals devoted to the crippled. Of the country’s four hundred doctors serving more than eleven million people, compared to. for instance, more than eight thousand doctors in Ontario serving six million, none specialized
in this branch of medicine. There was no such thing as a Moroccan physiotherapist. Again Morocco asked for outside aid. Their request went to WHO and to the League of Red Cross Societies in Geneva.
At the same time, the Moroccans set about trying to get the polluted cooking oil off the market, and trying to stop anyone who had already bought it from using it. These proved formidable tasks. Ninety percent of the Moroccan artisan class is illiterate; posted messages did little good. Radios, of course, are an unheard of lu> ury. The government sent loudspeaker trucks through city areas, and set up a painstaking house-to-house and store-tostore search by soldiers, police and specially organized flying squads. Even when the poisoned oil was discovered in homes, the searchers had a hard time convincing people they should give it up—-cooking oil was just too valuable. When the government announced there would be small pensions for victims of the oil, a few of the very poor are believed to have taken it deliberately.
The searchers screened the wares of thousands of small merchants assembled in open-air souks, or bazaars. Months later, some samples were still turning up. (The most serious charge of all, that merchants knowingly shipped polluted oil out of Meknès for sale elsewhere during the search, has never really been proved.)
The confiscated supply eventually filled several large warehouses, enough TCP to eripple many times the actual number of its victims.
As the first step of the relief program, WHO sent to Morocco, as a sort of advance scout. Professor Denis Leroy of France. Dr. Leroy’s job was to discover what could be done, and to suggest to WHO and the League who should go about doing it. His suggestions, long and detailed, formed the actual plan of attack. In essence. they were this: since the paralysis did not appear until after the TCP had run its course, there was no way to arrest the development of the disease; nor could there be any real “cure.” The program was to be one of rehabilitation—of teaching the victims to use new muscles to replace those that had been rendered useless, and of teaching them how to live with their handicaps.
This branch of medicine is one in which Canada excels; work done here on the rehabilitation of polio victims, for instance,
is world-renowned. Further. French-speaking Canadian doctors would be of extra value in Morocco, whose second language is French. When the League of Red Cross Societies issued its call for help to eightyfive member countries, Canada responded energetically. In the eighteen months of the relief program, from January 1, 1960, to June 30, 1961. no nation did more to help. Canada sent six doctors and seventeen physiotherapists to Morocco, as well as quilts, sheets, clothing, relief kits and medical supplies. For twelve of the eighteen months, a Canadian directed the program.
The first of the three doctors from Canada to hold this job was Dr. Gustave Gingras, a stocky, cigar-smoking one-man gang who was and is director—and the guiding light—of the Rehabilitation Institute of Montreal. When the League called the Canadian Red Cross Society, national commissioner W. Stuart Stanbury sought out Gingras for advice on whom to send. Gingras was lecturing in Buffalo. "I hat sounds interesting,” he told Stanbury. "I 11 go myself.” Shortly after, he took off for Geneva, and two days before Christmas arrived in Morocco, the first member of the international Red Cross group on the scene.
On Christmas day, 1959. he welcomed thirty doctors and physiotherapists from several countries and started them on two-day cram course on Moroccan politics, geography and social customs.
The Moroccan government, with Dr. Leroy of France consulting, had already allocated a few buildings as treatment centres, in Sidi Slimane, Sidi Kacem, Meknès and Khemisset. the four points forming, roughly, a north-south crescent through what had now become the epidemic area. Severe cases were to be taken to a special hospital in an old barracks at Fez, northwest of Meknès. Another hospital was to be set up at Alhucemas, on the Mediterranean coast in former Spanish Morocco, to care for patients brought down from the Rif Mountains.
Gingras found, however, that the plan sounded better than the reality looked. At Sidi Kacem, the building cleared for Red Cross use had been a morgue. The one in Meknès had been a house of prostitution. The other buildings were former barracks and garages. The international staff was billeted in private homes, hotels and a maternity hospital.
In the early days of the outbreak, while Moroccan doctors were trying such futile measures as massive injections of vitamin
B-12. many of the victims had tried to treat themselves in truly primitive ways. A few had sought quinine, thought to be a cure-all. More had applied leeches, or visited local healers for sessions of blood-letting. Their wrists, ankles and foreheads were encircled with hundreds of tiny cuts. Many had simply lain down on their hut floors or on rugs, resigned to the will of Allah.
With the arrival of the international team, the Moroccans’ attitude changed drastically — partly because of the government's allowance to registered oil victims. Crowds broke down the gates of the Meknès rehabilitation centre on the day it opened.
Gingras broke protocol by making sure that his working units would be truly international. In most previous Red Cross programs. each nation's teams had remained intact. To get the most varied possible mixture of language and scientific experience Gingras broke all of them up, except the Swiss, who refused. Even the two-woman team from Australia, nicknamed Big Kangaroo and Little Kangaroo by their coworkers, was split up. The first task of these mixed teams was to see exactly what their problems would be, to classify the victims. In rooms heated by Canadianmade kerosene-burners — North African winters can be cold — they set to work. Patients were asked to perform such simple acts as, when lying on a table, to wiggle their toes. “They thought we were crazy,” Gingras recalled recently. “But it was absolutely essential to know the extent of the paralysis. Without that knowledge, we wouldn’t have been able to map out a treatment program. None of the Arabs was hysterical — which might have accounted for some of the symptoms in a more sophisticated country. But some were great simulators of impossible symptoms, and these were doubtless healthy men who were trying to collect the government allowance for victims.”
By the end of February, the Red Cross teams had examined—and begun to treat the most serious cases among—6,300 victims, almost two-thirds of the 10,466 that were to register by the end of the program. Of the first group, 1,844 were children under fifteen. Sixty percent of the older victims were women. Gingras’ teams also found that sixty percent of the victims had paralysis of the hands as well as feet, and that in fifteen percent paralysis had reached the legs and hips. At this point, the world’s press was reporting the worst, and many people thought, as one leading U. S.
magazine said, "most of the victims can look forward to a life-time as cripples.” Gingras didn’t agree. In March, he was able to predict—quite correctly, as it turned out—that only six percent of the victims would be permanently disabled.
The second phase of the program, the real beginning of treatment, was under the supervision of Dr. Max Desmarais, of Winnipeg. Desmarais, a slender, aristocratic native of Mauritius, had come to Winnipeg via England in 1953 to help treat victims of two severe polio epidemics. He is now director of physical medicine at
Winnipeg Municipal Hospitals. ( The third Canadian chief delegate, who took over from Desmarais at the end of May and served until December I960, was Dr. Bertrand Primean. Primean at the time was director of rehabilitation services for the Department of National Health and Welfare. He is now working at Dr. Gingras’ institute in Montreal. The final two chief delegates were Swiss.)
Despite the complex nature of the disease they were treating, the Red Cross team devised now new methods in the year and a half of their program. Contributions
to medical research, in fact, were negligible during the Moroccan oil tragedy. The complex instruments and electrical equipment that would be needed to probe the neurological results of the poison effectively, simply couldn’t be obtained or maintained, under the conditions. (A team of French neurologists, who arrived there after the end of the program, may have some findings to report this summer.)
The immediate problem was to conduct the therapeutic work without the equipment of a modern hospital. "We found,” Gingras says, "that equipment wasn’t as
important as a good pair of hands. Instead of complicated weights, we used stones or bags of sand. We set up a lot of group work, so that one therapist could show exercises or simple corrective motions to a lot of people at once. I notice that some of the therapists who were with us at Morocco do a lot more group work now. at the institute.”
Under Desmarais, the Red Cross began teaching Moroccan aides to do some work as therapists—a program that has had longterm good effects for Morocco. Many of the patients who had individual attention became so attached to their therapists that when they were transferred to another clinic they would later seek out their first therapists to show off progress. Though most of the therapists w'ere women, there were some problems in treating the Moroccan wives. Even alone with the therapists, they would sometimes refuse to remove their veils, though they thought nothing of nursing babies between and even during therapeutic exercises.
At first there was little social contact between the Red Cross workers and the patients. But as the months wore on, the Moroccans cautiously began to invite
some of the foreigners to their homes. By summer, many of the Red Cross people were giving off an aroma of orange blossom perfume, which was showered on them ceremoniously at the threshold of the homes they visited. At the end of every visit, there was an exchange of small gifts. One Quebec physiotherapist had to refuse a baby girl, pressed on her by a Moroccan mother whom she had helped.
How much help did the Red Cross program, the biggest ever undertaken, actually give? On sheer statistics, the restorations were astonishing-—eighty-five percent of the 10,466 victims were listed as completely cured. Only 272 required further treatment—such as orthopedic surgery—after June 30. 1961. About that many more needed further medication. The remainder were “partly” cured. But, without damping the glow of the Red Cross achievement, it should be pointed out that "completely cured” means something else in Morocco than it would in North America. The Arabs, the Red Cross workers noted, seemed to attach no stigma at all to physical deformity. Such afflictions—or what we would call afflictions — as the shuffling "steppage gait” mean nothing but minor inconvenience to a Moroccan of the artisan class. Indeed, among all the lists of victims, there were, apparently, no psychological overtones.
The “completely cured” can go to work, can look after their families, can get from place to place.
The only permanent monument to the Moroccan epidemic is the treatment centre at Fez, now a permanent rehabilitation hospital open to any Moroccan needing specialized care and staffed by Moroccan physiotherapists, many of whom were trained by Canadians. There is still one Canadian physiotherapist at Fez. and this spring a young graduate Moroccan doctor applied to come to Montreal to take specialized training in the medicine of rehabilitation. Jy