Vincent (Ċensu) Tabone, an Ophthalmologist and a President of the Republic of Malta FREE

The Republic of Malta is an archipelago of small islands in the center of the Mediterranean Sea, between Sicily and Tunisia. Vincent (Ċensu) Tabone was born on March 30, 1913, on Gozo, the second largest of the 3 islands of Malta.¹ He was the youngest of 10 children. His father, a physician and surgeon working as a governmental medical officer, died when Tabone was only 9 years old. As a result, he was brought up in modest circumstances.

All Gozitan natives who wanted to advance in the world had to leave the island for further education, so at age 11, Tabone was sent to a Jesuit boarding school on the main island of Malta.¹ Despite being unhappy away from his family, he spent 6 years in school there and was an excellent student; Latin and history were his favorite subjects. At school, he learned English and Italian, which were in common use in Malta at the time.

In 1930, when he was 17, he enrolled in the University of Malta to become a physician like his father and his 2 older brothers. The 7-year term of study consisted of 3 years to complete the Bachelor of Science degree, followed by 4 years of medical school. Tabone took an early interest in politics; while at the university, he ran unsuccessfully (losing by 1 vote) to become president of the Student Representative Council.

Tabone received his medical degree and a degree in pharmacy in 1937; he then began his practice as a general physician. As was the custom at the time, he worked at a pharmacy, where patients came to consult with him. He remembers that his first patient had conjunctivitis. Life as a general physician was demanding, and the pay was low. He wished to specialize in ophthalmology because of the high incidence of trachoma in Gozo, but there were no ophthalmologic training opportunities in Malta (Paul Cauchi, FRCOphth, consultant ophthalmologist and grandson of Tabone; oral communication; May 10, 2010).

When World War II broke out in September 1939, Tabone immediately volunteered for the Royal Malta Artillery regiment and was commissioned as a lieutenant in the medical service. He served as a regimental medical officer at various military hospitals on the island for the duration of the war; after a year of service, he was promoted to the rank of captain. As the war moved away from Malta in 1944, his army duties were less onerous and his final hospital posting gave him the chance to become an ophthalmic trainee with a British ophthalmologist, an opportunity that might not have been possible if not for the war.¹

Tabone was demobilized from the armed forces in 1946 and was awarded a scholarship that allowed him to travel to England for postgraduate training. Initially, he was a house officer at the Moorfields Eye Hospital in London and obtained his Diploma in Ophthalmic Medicine and Surgery in 1947 from the Royal College of Physicians of London and the Royal College of Surgeons of England. He then attended the University of Oxford, taking a 2-month course with Professor Ida Mann; there, Tabone earned his Diploma in Ophthalmology. He studied ophthalmic surgery at Addenbrooke's Hospital in Cambridge. Overall, he spent a year in England. After returning to Malta, he still felt the need to obtain a fellowship in addition to his 2 diplomas; he took a correspondence course from Edinburgh University in Scotland for the specialized degree in ophthalmology that was not available from the Royal College of Surgeons of England. In 1949, he worked at the Royal Infirmary in Edinburgh for 2 months and took the written examinations to obtain the Fellowship of the Royal College of Surgeons of Edinburgh, specializing in ophthalmology (Vincent Tabone, MD; written communication; September 5, 1949). Tabone was the first Maltese national to obtain this fellowship (Records of the Royal College of Surgeons, Edinburgh, Scotland; written communication; November 16, 2010).

With these impressive credentials, Tabone became one of Malta's leading ophthalmologists for the next 40 years. He performed all types of ophthalmic surgeries, including cataract surgery using Graefe sections and the cryophake, retinal detachment surgery using diathermy and scleral buckle, strabismus surgery, and a wide range of oculoplastic surgery. He was a strong proponent of using local anesthesia in surgery rather than the more commonly used general anesthesia and was one of the first ophthalmologists to introduce contact lenses into the country (Paul Cauchi, FRCOphth; written communication; September 24, 2010).

Trachoma was a huge problem in Malta. It became endemic when the Egyptian ophthalmia spread from British troops who were garrisoned in Malta after having been evacuated from the Egyptian campaign of 1802.² The disease spread through the population due to the usual causes: poverty, poor personal and communal health, and general ignorance of the causes and treatment of the disease by physicians and the lay population. For example, in 1901, 72% of all patients treated at the Ophthalmic Institute of Malta had conjunctival afflictions, of which most were trachoma. Trachoma was the leading cause of ocular disease in the islands, even more than cataract. On Gozo, 30% of all families had at least 1 member affected.^3- 4

In 1948, the government of Malta established a program to send an ophthalmologist to Gozo to develop a program to evaluate and treat trachoma with the use of sulfonamides, which had been introduced into the treatment of trachoma a decade earlier. Tabone was appointed to this position and became a consultant at the Gozo Hospital. He examined 4058 schoolchildren and found 721 cases of trachoma, an incidence of 17.8%. Oral sulfonamides, sulfa drops, and sulfa ointment were used as treatment. The results of this campaign were excellent: after 2 years of treatment, the incidence was reduced to 6 cases (0.15%). However, when Tabone presented his data at the XVI International Congress of Ophthalmology in London in 1950, his findings were received with doubt. Some of the older ophthalmologists were skeptical of his results, still convinced that no cure for trachoma existed; they argued that Tabone was curing only the secondary infections.⁵ Tabone published his results in the British Medical Journal in 1951.⁶ This article gained attention in the field of trachoma research and was subsequently reprinted in 2 other journals dedicated to trachoma (one in French and the other in Italian) and thus gained better credence and publicity for his conclusions. Tabone continued to work on this project in Gozo for more than 10 years; in his last report, in 1960, he found the incidence of trachoma in the school population to be 0.3% (Vincent Tabone, MD; written communication; December 31, 1960). The fact that trachoma was markedly reduced but still present after 10 years of work shows how persistent such a campaign must be for complete eradication of this disease.

This small-scale pilot program gave Tabone many insights into how to eradicate trachoma; he became a pioneering expert in this field. The main conclusions that he learned and subsequently taught worldwide were as follows: eradication of trachoma in countries where it is endemic requires a detailed, nationwide campaign underwritten and supported by the government, and simply treating individuals on a case-by-case basis will not work. Prospective and universal screening, compulsory notification of the presence of trachoma, and compulsory treatment free of charge for all infected persons must be provided. Careful epidemiological findings must be recorded to document the extent of the incidence of trachoma and to show the progress of the eradication campaigns. Extensive public education must be used to inform the population of the necessity for this campaign; the importance of personal and communal hygiene and sanitation must be stressed. The incidence of trachoma in school-aged children was found to be 4-fold that of adults; because children serve as the reservoir for recurrent infections, children and infants should be treated preferentially. His treatment of choice was sulfonamides taken orally, which he found more effective than when used topically. He also used aureomycin (chlortetracycline hydrochloride) or terramycin (oxytetracycline) topically. The most serious problem he encountered in implementing his campaign was adherence to the treatment program; hence, Tabone always emphasized that teachers or school physicians should administer the drugs on a regular basis. He was concerned about reinfection rates and advocated that the length of an antitrachoma campaign should be no less than 3 years. He noted that the use of mechanical and surgical methods of treatment of trachoma would become unnecessary in the vast majority of patients and predicted that, eventually, the disease could be abolished,⁷ a goal that is nearing fruition today.⁸

In 1948, the newly established World Health Organization (WHO) joined with other organizations that had previously worked for international trachoma control prior to World War II and organized the Study Group on Trachoma. In alliance with the United Nations (UN) Children's Fund, the WHO set up programs for worldwide trachoma control, and the first Expert Committee on Trachoma met in 1952.⁸ On the basis of his experience and published results from his program on Gozo, Tabone was the first ophthalmologist hired by the WHO as a consultant. He immediately embarked on extensive travel to other countries to replicate his antitrachoma campaign. He worked initially in Asia, spending 6 months visiting many countries, including Taiwan, Indonesia, Borneo, Malaya, Hong Kong, the Philippines, Singapore, Vietnam, Cambodia, and Sarawak (Figure 1). He met with the local ophthalmic practitioners and guided them in setting up trachoma control programs. He also performed surgical procedures and documented the high incidence of vitamin deficiency with keratomalacia as another cause of blindness (Vincent Tabone, MD; written communication; date uncertain). Reading the 68 typewritten pages of his reports from these missions reveals the intensity and enthusiasm of his work.

Taiwan was his greatest challenge because trachoma was widespread there. When he first arrived in 1952, he estimated the incidence of the disease to vary between 44% and 90% of the population and found that 18% of all patients with trachoma were blind (Vincent Tabone, MD; written communication; October 16, 1952). The main focus was treatment of schoolchildren with oral sulfa drugs followed by topical chlortetracycline hydrochloride. A year later, when he returned to Taiwan, he documented that 86% of trachoma cases had been cured (Vincent Tabone, MD; written communication; July 25, 1953). These campaigns were so successful that when Tabone returned to visit Taiwan 20 years later, a former ophthalmologic colleague with whom he had worked told Tabone that he could no longer find active cases of trachoma to demonstrate to his students. Tabone said this was one of the proudest moments of his life.

From 1952 to 1960, these international travels and consultations were a large part of his professional life. He was appointed a member of the WHO Expert Committee on Trachoma for a 5-year term.⁹ As his reputation spread, he was requested to consult and advise on trachoma eradication in other countries such as Iraq, Egypt, Tunisia, and Sudan.

While still practicing ophthalmology and working with the WHO, he became a founder and the first president of the Medical Officers Union of Malta, protesting against low pay for and political control of physicians employed by the Labour-controlled government.¹ For 10 years he served as president of the physicians' union, now known as the Medical Association of Malta. This event marked his transition from ophthalmology to national politics.

Tabone first ran for a seat in parliament in 1962 but failed to win the election. He was a strong adherent to the beliefs of the Nationalist Party, which favored Maltese independence from the British Empire but with continuing ties to Western democratic nations and membership in the British Commonwealth. Tabone was affiliated closely with his local parish church and with the Sliema Philharmonic Society, of which he was president for 29 years.¹ The organization was an example of a band club, a type of local group found throughout Malta that provides musical, social, and cultural activities in its neighborhood and also has great political influence. Tabone was approachable to all members and classes of society and was embraced as a “people's politician.”

Although Tabone held no governmental office after his first failed bid for parliament, he cultivated his political skills as the secretary general of the Nationalist Party and served in this post for the next decade.¹ His job was to reorganize the structure of the party. He increased and regularized party membership, developed an outreach program with the formation of a women's section, and kept careful minutes of the executive meetings.

In the election of 1966, at age 53, Tabone was elected handily to parliament and was returned to that office in the next 4 elections through 1987. His party had become the ruling party, and he was invited immediately to become a cabinet minister. He was not asked to be the Minister of Health but the Minister of Labour and Social Welfare.¹ Because his governmental position was considered a full-time job, he had to suspend his ophthalmic practice and, thus, he suffered financially. As a physician, Tabone used his formal first name, Vincent. But as an indication of his devotion to the national service he was undertaking, when he was first appointed to the Cabinet, he took the oath of office using his childhood nickname, Ċensu, an abbreviation of Vinċensu, the Maltese version of Vincent. During his political and governmental career and to this day, he continues to be known as Ċensu.

Tabone's main ministerial concerns were unemployment and job creation, labor-industrial relations, and measures to alleviate economic and medical problems for elderly, widowed, orphaned, and handicapped individuals. In 1968, as a result of his cabinet experience, he submitted a proposal to the General Assembly of the UN calling attention to the needs of the world's growing number of elderly individuals. Tabone clearly foresaw increasing human longevity and the consequently increasing burden on governments to support elderly individuals. His proposal led to the establishment, in 1988, of the UN International Institute on Ageing, an organization that continues to function from its headquarters in Malta.¹⁰

In the general elections of 1971, Tabone's Nationalist Party was voted out of office and was replaced for the next 16 years by the Labour Party. Tabone continued to serve in parliament in the opposition party as shadow Minister of Foreign Affairs and the spokesman for his party for international relations. Since being a member of parliament was considered a part-time job, he was able to resume his ophthalmic practice. Tabone served as a member of the Maltese delegation to the Council of Europe in Strasbourg, France, and served as the chairman of its Committee of Ministers. He advocated for human rights for political dissidents in the Soviet Union, helped develop organizations to foster democratic institutions throughout Europe, and spoke out strongly against totalitarian governments.¹

In 1987, as a result of his party's electoral victory, Tabone became the Minister of Foreign Affairs. Tabone was instrumental in calling for the European nations to defend the world's climate against man-made threats and was one of the first world statesmen to propose climate control and environmental protection of the seas. In 1988, he addressed the General Assembly of the UN and proposed a resolution, “Conservation of Climate as Part of the Common Heritage of Mankind.” This led to the unanimous adoption of a UN resolution on climate protection to reduce man-made environmental impact.¹

In 1989, Tabone was active and vigorous at age 76. At that time, his party selected him to serve in the largely ceremonial office of president of the Republic for a 5-year term (Figure 2). According to the Maltese constitution, this position is given not as the result of an election by popular vote but by a vote of the members of parliament. Tabone was the first president elected from the Nationalist Party. On the international scene, the first major event of his presidency was hosting the summit meeting in Malta in 1989 between Presidents George H. W. Bush and Mikhail Gorbachev that ended the Cold War. Other important events included the visit of Pope John Paul II (the first pope ever to visit Malta) and the visit by President Richard von Weizsäcker of the newly reunified country of Germany that served as a healing act to end bitterness left over from the German attacks during World War II. Tabone was so well regarded at the end of his term that the opposition Labour Party asked him to continue as president for a second term, an unprecedented offer. However, Tabone declined; in 1994, he retired from public service and the medical profession at the age of 81.¹

In retirement, he continued to keep up with current events and taught a course at the University of Malta. He continued his hobby, repairing old clocks, particularly grandfather clocks. According to an anecdote, when he became president, he personally mended some of the old clocks in the presidential palace and office that had not worked in years.

Tabone served as a dedicated ophthalmologist for 40 years and as a successful public official for 30 years. Either of those jobs would have sufficed for most people. Which was more satisfying to him? Obviously, he was inspired to improve the governance of his country and so assumed a major role in politics and government, always advocating strong democratic and humanitarian policies. From his appointment as secretary general of the Nationalist Party in 1962 to his retirement in 1994, he served 5 terms as a member of parliament and held 2 positions as a cabinet minister, with his career culminating in a successful and historic term as president of Malta.¹

Tabone was widely recognized as an outstanding statesman and diplomat in Europe and was decorated by 9 European countries. The Council of Europe honored him by issuing a postal stamp with his portrait on it. Malta awarded him its highest civil honor, the Companion of Honor of the Order of Merit. He received honorary degrees from the University of Malta and from the Beijing Medical College in China. Perhaps his most singular honor was the award of the Presidential Gold Medal from the Royal College of Surgeons of Edinburgh. This medal was given for his contributions to ophthalmology and his election as president of Malta. This award is not given on a regular basis but serves to acknowledge great contributions by a fellow of the college (Records of the Royal College of Surgeons; written communication; November 17, 2010).

Tabone openly said that he missed ophthalmology when he had given it up. He maintained that his proudest achievements were in ophthalmology, not politics (Paul Cauchi, FRCOphth; written communication; May 10, 2010). His role in eradicating trachoma, first in Malta and then as a WHO consultant in many foreign countries, was his greatest satisfaction.