Health-Care For All: History of a ‘Third-World’ Dilemma

By Gordon Charles Cook

In the 1960s to 1980s, a heated controversy arose as to how best medical care could be delivered to individuals living in rural 'third-world' communities. This became polarised: should the national health budget be directed to primary health care with the exclusion of tertiary care (including hospitals)? This became confused with the training of medical personnel, including doctors. Of course, a balanced approach is what is required.

Now that the NHS under the present government is rapidly becoming oriented towards primary health care, this third-world controversy of nearly half a century ago might well be worthy of consideration. After a decade, and more, working in Nigeria, Uganda, Zambia and Saudi Arabia, as well as in Papua New Guinea, the author became increasingly convinced that a balanced viewpoint, i.e. between curative and preventive medicine was both essential and the only way forward in both developing and developed countries. That is a simple 'message' and the underlying theme in this book.

About the author: Professor Gordon Cook, DSc, MD, FRCP is a physician with a special interest in tropical and infectious diseases, and a medical historian; he was formerly a Medical Specialist, Royal Nigerian Army; Lecturer in Medicine, Makerere University, Uganda; Professor of Medicine, The University of Zambia; Professor of Medicine, Riyadh University, Saudi Arabia; Professor of Medicine, The University of Papua New Guinea; Visiting Professor of Medicine, The Universities of Basrah and Mosul, Iraq; and Visiting Professor, Quatar.

• Language: English
• Publisher: Amolibros
• Release date: Apr 10, 2013
• ISBN: 9781908557452

Gordon Charles Cook

Professor Gordon Charles Cook, DSc, MD, FRCP is a physician with a special interest in tropical and infectious diseases, and a medical historian; he was formerly a Medical Specialist, Royal Nigerian Army; Lecturer in Medicine, Makerere University, Uganda; Professor of Medicine, The University of Zambia; Professor of Medicine, Riyadh University, Saudi Arabia; Professor of Medicine, The University of Papua New Guinea; Visiting Professor of Medicine, The Universities of Basrah and Mosul, Iraq; and Visiting Professor, Quatar.

Book preview

Health-Care For All

history of a ‘third-world’ dilemma

G C Cook, MD, DSc, FRCP, FRCPE, FRACP, FLS

Visiting Professor, University College London

Published as an ebook by Amolibros at Smashwords 2013

AMOLIBROS

About this book

In the 1960s to 1980s, a heated controversy arose as to how best medical care could be delivered to individuals living in rural ‘third-world’ communities. This became polarised: should the national health budget be directed to primary health care with the exclusion of tertiary care (including hospitals)? This became confused with the training of medical personnel, including doctors. Of course, a balanced approach is what is required.

Now that the NHS under the present government is rapidly becoming oriented towards primary health care, this third-world controversy of nearly half a century ago might well be worthy of consideration. After a decade, and more, working in Nigeria, Uganda, Zambia and Saudi Arabia, as well as in Papua New Guinea, the author became increasingly convinced that a balanced viewpoint, i.e. between curative and preventive medicine was both essential and the only way forward in both developing and developed countries. That is a simple ‘message’ and the underlying theme in this book.

About the Author

Professor Gordon COOK, DSc, MD, FRCP is a physician with a special interest in tropical and infectious diseases, and a medical historian; he was formerly a Medical Specialist, Royal Nigerian Army; Lecturer in Medicine, Makerere University, Uganda; Professor of Medicine, The University of Zambia; Professor of Medicine, Riyadh University, Saudi Arabia; Professor of Medicine, The University of Papua New Guinea; Visiting Professor of Medicine, The Universities of Basrah and Mosul, Iraq; and Visiting Professor, Quatar.

Copyright © G C Cook 2009

First published in 2009 by TROPZAM

11 Old London Road, St Albans, Herts, AL1 1QE

www.tropzam.co.uk

Published electronically by Amolibros 2013

http://www.amolibros.com

The right of G C Cook to be identified as the author of the work has been asserted herein in accordance with the Copyright, Designs and Patents Act 1988.

All rights reserved. This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold, hired out or otherwise circulated without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library.

This book production has been managed by Amolibros

eBook conversion by Oxford eBooks Ltd.

www.oxford-ebooks.com

Prevention is better than cure*

(early seventeenth century proverb)

---

* E Knowles (Ed). Oxford Dictionary of Quotations. Oxford : Oxford University Press 6th ed. 2004; 69.

Contents

Preface

Prologue

1 An exemplary dialogue

2 A second dialogue from Papua New Guinea

3 ‘Health-care’ in developing countries; the problems exposed

4 Some proposed solutions to the dilemma

5 Politics and altruism dominate the debate; idealists in the ascendancy

6 A traditional (orthodox) approach

7 Are hospitals necessary?

8 Teaching : the under-graduate curriculum

9 Teaching : post-graduate education

10 The Department of Community Medicine, and the Ministry/ Department of Health in ‘delivery of health-care’

11 Medical research in the developing world

12Conclusions, and some suggested solutions to the dilemma

Epilogue

Index

Preface

Of course, prevention is better than cure, especially from the viewpoint of economics; but how is this to be achieved? The present British government would like to know the answer to what has escalated into a political dilemma.

Preventive medicine had its origin(s) in the Royal Navy and Army; in the former James Lind (1716-94) and Gilbert Blane (1749-1834), and in the latter John Pringle (1707-82) were largely responsible for improvements. Preventive medicine in England thus ‘took off’ in the eighteenth century. It was an attractive idea to prevent disease in populations, rather than care for individuals.

During years in which I held several senior positions in clinical medicine in developing counties, a heated controversy arose concerning the correct balance involving prevention versus cure in those countries. The discussion, which was aired in local, national and international media, became, in the 1960s-80s, to a large extent polarised; should far more resources be put into primary care in rural areas, with relative neglect of tertiary care? In view of my position, I strongly backed preservation of the latter, recognising that a fine balance should ultimately be sought, and what is correct for one country is probably wrong for another. One of the most distinguished hospital administrators of the nineteenth century – Sir Henry Burdett (1847-1920) – certainly recognised not only a requirement for hospitals, but also the need for local ‘cottage’ hospitals close to the individual’s place of domicile. ¹

Regrettably, this controversy became confused with the training of doctors and senior medical personnel, which many claimed should also be undertaken in rural areas. ² I believed this approach to be highly impractical, if not impossible.

After a decade, and more, working in Nigeria, Uganda, Zambia and Saudi Arabia, as well as in Papua New Guinea (PNG), I became increasingly convinced that a balanced viewpoint, i.e. between curative and preventive medicine, was both essential and the only way forward in both developing and developed countries. That is a simple ‘message’ and an underlying theme in this book.

The present British government, now the guardian of the sacred political cow initiated by Aneurin Bevan³ in 1946, is clearly backing a primary-care strategy⁴, and is in danger of losing sight of the fine balance required between these two approaches. A recent editorial in the British Medical Journal for example, declared: ‘… With a shift in the UK towards practice-based commissioning the primary care view is set to prevail [in the NHS]’.⁵ Maybe the time has come, therefore, for a serious re-examination of a similar controversy which raged in the ‘third-world’ several decades ago. I maintained then that medical care required both components, and training of medical students and other medical personnel cannot be de-centralised, to anything like the extent many of the idealists were recommending. Excessive decentralisation is also presently being recommended in other professions also to a greater or lesser extent, but I suggest in this book that the situation in medicine in the ‘third-world’, exemplifies the controversy.

A good deal of this discussion centres on PNG because it was whilst I was there that much of the debate took place very largely in the wake of the explosion of writings on this subject in the 1960s and ’70s, which advocated massive changes in the direction of both training and ‘delivery of the goods’. PNG had, at the time of writing, enjoyed nearly a decade of independence from colonial rule, but possessed no adequate teaching hospital, and no indigenous medical practitioner trained to an international level of excellence in any medical specialism; such a situation, I considered, gave cause for grave concern.

This book is therefore in the main, an historical review based on literature of nearly half a century ago, regarding a correct balance in health-care resources for the ‘third-world’. I initially wrote the manuscript in PNG in 1980, but have updated it in 2007.

Many viewpoints in this book are my own and have been founded on my own experience of academic medicine in ’third-world’ universities. Most of the views expressed in Chapters 1 and 2 have their origin in idealist (Utopian) sentiments expressed by British doctors – most of upper middle-class background – as well as North Americans, working in newly independent African countries.

G C Cook

December 2007

---

References and Notes

¹ C Singer, E A Underwood. A Short History of Medicine. 2nd ed. Oxford : Clarendon Press, 1962 : 209-32; R Acheson, P Poole. The London School of Hygiene and Tropical Medicine : a child of many parents. Med Hist. 1991; 35 : 385-408; G C Cook. Tropical Medicine : an illustrated history of the Pioneers. London : Academic Press, 2007 : 228-9; G C Cook. Henry Charles Burdett (1847-1920) : outstanding hospital administrator, successful secretary of the Seamen’s Hospital Society, and notable philanthropist. J Med Biog. 2001; 9 : 195-207; W Moore. A man who called hospitals to account. Br Med J. 2007; 335 : 828.

² G C Cook. Training of doctors and delivery of health care in developing countries. Lancet. 1979 ; ii : 297-9.

³ Aneurin Bevan (1897-1960) was the labour minister of health in Clement Attlee’s administration, from 1945 until 1948; he was the principal architect of the National Health Service Act 1946. [See also: M Foot. Aneurin Bevan 1897-1960. London : Victor Gollancz, 1997 : 634; D Smith. Bevan, Aneurin (Nye) (1897-1960). In: H C G Matthew, B Harrison (eds). Oxford Dictionary of National Biography. Oxford : Oxford University Press, 2004 ; 5 :566-73].

⁴ G Meads (ed). A Primary Care-led NHS: putting it into practice. London : FT Healthcare, 1996 : 254 ; R Q Lewis. A new direction for NHS community services. Br Med J. 2006 ; 332 : 315-6 ; N Britten. Patient Agendas in primary care. Br Med J. 2006 ; 332 : 1225-6 ; C Ham. Reforms to NHS commissioning in England. Br Med J. 2006 ; 333 : 211-2.

⁵ F Godlee. For patient or population (editorial). Br Med J. 2007 ; 334 : 908.

Prologue

Improvements to medical infrastructure, especially within urban areas, led to a significant decline in premature morbidity and mortality in Britain during the Victorian era (1837-1901). ¹ As in the developing world today, the bulk of premature morbidity and mortality was from infectious disease. ² Prior to the development of the ‘germ theory’ of disease (by, among others, Pasteur, Lister and Koch) and many years before the introduction of antimicrobials, enormous advances in human health had therefore taken place.³ These resulted first and foremost from improvements in the prevailing infrastructure in the rapidly increasing number of urban conurbations.

A major early protagonist for an improvement in the basic standards of living conditions had been Thomas Southwood Smith (1788-1861) – the ‘father of sanitary reform’.⁴ Initially trained for the dissenting Christian ministry, Smith was appointed at the age of thirty-six years, physician to the London Fever Hospital. Other prominent medical names in disease prevention at that time were: Neil Arnott (1788-1874) and James Kay, later Sir James Kay-Shuttleworth (1804-77). Factors in the spread of epidemic disease (most of which in Smith’s opinion had a ‘telluric’ origin) were: confinement within limited space, overcrowding, and decay of vegetable/animal material – which contaminated the atmosphere (the ‘miasmatic’ theory of disease). In 1839 (two years after Victoria came to the throne), it was Smith who was largely instrumental in forming the Health of Towns Association. In 1848, he was appointed sole medical representative on the General Board of Health, on which he had a close liaison with the lawyer Edwin Chadwick (1800-90).⁵

At the beginning of the Victorian era, therefore, many preventive strategies had been well established. Guy has emphasised that space, ventilation, drainage and water supply, as well as cleanliness were of paramount importance. He also emphasised that good health is vital to the labourer, and furthermore that disease is overall very costly to a nation. Florence Nightingale (1820-1910) highlighted reforms in hospital design, and concentrated her efforts on improved ventilation;⁶ the new St Thomas’s Hospital designed by Henry Currey (1820-1900) was one of the first institutions to incorporate the ‘pavilion principle’ (to replace the ‘corridor plan’) with improved ventilation.⁷ From the mid-nineteenth century, there had been increasing recognition that many of Chadwick’s ‘filth diseases’ resulted from poor standards of sanitation and overcrowding. In this context, John Snow (1813-58), although his views were not widely accepted in his life-time, was an important pioneer.⁸ Incidentally, Snow’s mind on this issue was made up long before he published his widely acclaimed work on cholera-prevention in 1854 and ’55; in a lecture, which is rarely quoted, given to the Medical Society of London in 1853, for example, he had outlined his seminal views on the cause and prevention of faecally-transmitted infections by a specific agent which was certainly not a miasma. ⁹ The development of ideas on cholera transmission during the nineteenth century is illustrated in accounts given by George Roupell (1797-1894) in 1833 and Joseph Fayrer (1824-1907) in 1888, respectively. ¹⁰ The major contributions during this era were therefore based on implementation of much of what was already known in the eighteenth century and before.

Joseph Bazalgette (1819-91), ¹¹ Chief Engineer to the Metropolitan Board of Works (the ‘sewer king’), was an early enthusiast for pure drinking water; coupled with satisfactory sewerage disposal he believed that this was of paramount importance in prevention of many faecally-transmitted infections. In fact, although an engineer, and not medically qualified, behind this work was the realisation (outlined in his Presidential address to the Institution of Civil Engineers) that both health and longevity of mankind could be improved by his work. As well as preventing a host of intestinal infections, including ones as diverse as thoset caused by Giardia lamblia and dracontiasis, this strategy decreased the prevalence of such diseases as amoebiasis and liver ‘abscess’ in London. ¹²

But this approach, i.e. improvement of the environment (Bazalgette’s sewers and Nightingale’s call for better ventilation in hospitals are but two examples), although urgently required in most developing countries, is not what the following debate is primarily all about. It has, as its underlying themes: (i) prevention of disease in individuals or the masses, and (ii) provision of health-care to rural communities.¹³

---

References and Notes

¹ W A Guy. Public Health: a popular introduction to sanitary science. Being a history of the prevalent and fatal diseases of the English population from the earliest times to the close of the War of the French revolution in 1815. London: Henry Renshaw, 1874 : 342; C Singer, E A Underwood. A Short History of Medicine. 2nd ed. Oxford : Clarendon Press 1962 : 209- 32; C Hamlin. Public Health and Social Justice in the Age of Chadwick Britain, 1800-1854. Cambridge: Cambridge University Press, 1998 : 368; S Szeter. Health and Wealth: studies in history and policy. USA: University of Rochester Press, 2005; G C Cook. What can the Third World learn from the health improvements of Victorian Britain? Postgrad Med J. 2005 ; 81 : 763-4.

² N P Shetty, P S Shetty. Epidemiology of disease in the tropics. In : G C Cook, A I Zumla (eds) Manson’s Tropical Diseases. 22nd ed. London: Saunders, 2009 : 9-17.

³ R T Thorne. On the Progress of Preventive Medicine during the Victorian Era. London: Shaw and Sons, 1888 : 63.

⁴ G C Cook. Thomas Southwood Smith FRCP (1788-1861) : leading exponent of diseases of poverty and pioneer of sanitary reform in the mid- nineteenth century. J Med Biog. 2002 ; 10 : 194-205.

⁵ Anonymous. Contagion and sanitary laws. Westminster Review, 1825 ; 3 : 134-67.

⁶ G C Cook. Victorian Incurables: a history of the Royal Hospital for Neuro- Disability. Spennymore, Durham: The Memoir Club, 2004 : 90-97.

⁷ G C Cook. Henry Currey FRIBA (1820-1900) : leading Victorian hospital architect, and early exponent of the ‘pavilion principle’ . Postgrad Med. 2002 : 78 : 352-9.

⁸ A E Shephard. John Snow, Anaesthetist to a Queen and Epidemiologist to a Nation: a Biography. Cornwall, Canada: York Point Publishing, 1995 : 373; S Johnson. The Ghost Map. London : Allen Lane 2006 : 300.

⁹ J Snow. On Continuous Molecular Changes, More Particularly in Their Relation to Epidemic Diseases. London: John Churchill, 1853 : 38.

¹⁰ G L Roupell. The Croonian Lectures, delivered at the Royal College of Physicians in MDCCCXXXIII on cholera. London: C & W Nicol, 1833 : 91; J Fayrer. The Natural History and Epidemiology of Cholera. London: Churchill, 1888 : 71.

¹¹ G C Cook. Joseph William Bazalgette (1819-1891) : a major figure in the health improvements of Victorian London. J Med Biog. 1999 ; 7 : 17-24; G C Cook. Construction of London’s Victorian sewers : the vital role of Joseph Bazalgette. Postgrad Med J. 2001 ; 77 : 802-4.

¹² J W Bazalgette. Presidential address. Minutes of Proceedings of the Institution of Civil Engineers ; with Other Selected and Abstracted Papers. 1884 ; 76 : 2-69.

¹³ T Pang. The need for action in global health policy. Lancet. 2006 ; 368 : 1485-6.

1

An exemplary dialogue

To prevent disease, to relieve suffering and to heal the sick – this is our work.

William Osler (1849-1919)

---

Despite its limitations, the Brandt report highlighted serious deficiencies in the sharing of global wealth between the developed (North) and underdeveloped or ‘Third World’ (South) countries¹; the world is thus divided, both philosophically and nationally, by a ‘poverty curtain’.² As responsible global citizens, members of the medical profession have an important rôle therefore, in providing a solution to those problems – not least, in the areas of nutrition, population control, and hopefully in influencing the ‘arms race’.³

Within the ‘Third World’, medical and paramedical personnel have an enormously important potential rôle; whilst many of those countries were producing such staff, in 1980 they still largely remained dependent on expatriates – both practically and more importantly in producing plausible strategies for a solution to these problems. That was largely because it was well nigh impossible, in most developing countries, to retain sufficient numbers of qualified doctors. The cost effectiveness of doctor-delivered health-care is relatively low, especially in rural areas of the developing world. Therefore appropriate methods of delivery of health-care had to be developed, and the medical auxiliary thus became the focus of much attention.⁴ As a revolt against bureaucracy, capitalism and high technology, and following an increase in political awareness, the Appropriate Technology Movement had been established. Much has been written on this subject in recent years; that resulted in a confused message in the minds of those seeking Utopia; one debate in particular centred around whether hospitals (including teaching hospitals) were in fact necessary in the ‘Third World’.

As an example, the population of Port Moresby, the capital city of Papua New Guinea (PNG) had been, and is presently increasing at a great rate. By any standard, the Port Moresby General Hospital (PMGH) was, in 1980, inadequate. Although opened as recently as 1957, it was no longer able to cater for the requirements of Port Moresby, let alone the whole country, and as a University Teaching Hospital it was totally inadequate. Most of the wards – until recently designated ‘Native wards’ – consisted of corrugated iron-roofed structures with rapidly decaying prefabricated walls (figs 1.1-1.7). The patients were in many cases exposed to the elements, and the standard of sanitation was appalling; it was frequently impossible for a patient to get a sheet to cover a mattress, let alone one to cover him/herself. Faecal odours were so pronounced that many found it impossible to tolerate this insult to human dignity; many complained that they could not eat their meals, so great was the stench. The hospital equipment was overall archaic; it was impossible to keep the buildings clean and consequently morale at all levels – not least amongst the nursing staff – was of a very low order. After a three-hour ward-round in this atmosphere, often at a temperature of >30ºC, and occasionally with vomit and faeces lying on the floor, it was virtually impossible to make an intelligent or accurate diagnosis. This was the major hospital for a country with a population of around four million!

The situation in some hospitals in Britain is now not too different; owing to excessive bureaucracy, an obsession with targets, absence of matrons and a gross excess of lay-administrators, nosocomial infections – including multi-antibiotic resistant Staphylococcus aureus and Clostridium difficile – are rapidly becoming out of control. It has even been suggested that Britain should take lessons in hygiene from the French,⁵ a suggestion that a few years previously would have been considered risible!

With this scenario (not too dissimilar to that in some hospitals in present-day UK) to the fore, I decided after considerable thought, therefore, because little or nothing was being done to improve this hospital, to communicate with the Editor of the national daily newspaper of Papua New Guinea. The following is a minimally edited version of my letter:

1.1 Port Moresby needs a modern hospital

History. The PMGH was officially opened in 1957 by the Deputy Prime Minister of the Commonwealth of Australia. It must already have been grossly inadequate, and was used only by Papua New Guineans; expatriates were treated at a separate MacGregor⁶ wing! (Immediately prior to independence, in 1974, all patients from all ethnic groups were treated at the PMGH; the MacGregor wing was used solely for obstetrics.) Development of the hospital took place on a piecemeal basis; that accounted for the grossly inadequate structure(s) which existed in 1980. In 1974, two wards (intermediate – whatever that means!), outpatient and casualty departments, pathology laboratories and the Clinical Sciences block were added. The end result was a grossly inadequate conglomeration of structures (mostly ageing ones), none of which was acceptable as an integral part of a major hospital in 1980. Development continued with the construction of an addition to the obstetric department. As the Health Minister had recently emphasised, standards of hygiene were very well below an acceptable standard – due not so much to the much blamed visitors, but to ageing plumbing and sanitary apparatus, including drains and lavatories. There was nowhere to isolate patients with infectious diseases. In the rainy season there were often lakes between the wards, where mosquitoes bred rapidly.

Fig 1.1: Wards of the Port Moresby General Hospital (PMGH) in 1980. The corrugated iron roofs are shown on the left; the connecting ‘corridor’ is at the right.

Fig 1.2: The main ‘corridor’ of the PMGH, with the medical ward to the right.

Fig 1.3: Three exterior views of some of the wards of the PMGH in 1980.

Fig 1.4: Exterior of the medical ward at the PMGH in 1980.

Fig 1.5: Swamp (which could encourage breeding of malaria-carrying mosquitos) between the medical and surgical wards at the PMGH during the rainy season of 1979.

Fig 1.6 : Two pictures of interior of the medical ward at the PMGH in 1980.

Fig 1.7: Young Papua New Guinean boy preparing a meal outside the medical ward at the PMGH in 1980.

Importance of the urban hospital. In health as in most other aspects of life in PNG, great emphasis had been put on the development of services for rural areas of the country; that was, and remains right and proper. However, in the minds of many (idealists) this should take place to the virtual exclusion of development in urban areas because 80 per cent, or thereabouts, of the population lives in rural areas. Although appealing to the idealist, that made (to my mind) little or no practical sense. It is I wrote, vital that a disproportionately high budget goes to the urban hospitals, not because the urban populations should have better medical-care than rural ones, but for reasons given below.

Special needs for medical services in Port Moresby. Port Moresby was and seemed extremely likely to remain the capital city of PNG. Therefore it must have a large, modern hospital able to cope with a rapidly increasing population. The spectrum of disease in Port Moresby amongst Papua New Guineans will unfortunately, I wrote, rapidly approach that of the ‘western world’; that is because people in the capital city will adopt lifestyles like those of the western world; there will for example, be a great increase in heart attacks, strokes, diabetes, etc. In addition, Port Moresby must have the major hospital in PNG, which is well staffed with specialist doctors, and able to cope with referrals of sick patients from all over the country. This hospital must also act as the medical reference centre for the country. PNG will require expatriates in senior positions in the professions, and in commerce and industry for many years to come; it will only attract the best (I wrote) if the medical services are seen to be substantially better than they were at that time. PNG had a tourist industry which I considered would only expand if there were excellent medical facilities at the major centre in the country; a high proportion of tourists are ageing ones from western countries who are liable to suffer heart attacks, strokes, etc.

Teaching medicine and allied subjects. Again, the idealist lobby (frequently expatriates somewhere left of centre, politically) argue that medical training and training of medical auxiliaries including nurses, nutritionists, physiotherapists, laboratory technicians, etc, should be carried out in rural areas, for it is there that the bulk of the population lives. For many reasons that is totally impossible if high standards are to be aimed at.⁷ If ‘delivery of health-care’ to rural areas is confused with medical education and dealt with