Zambezia (1983), XI (i)ALL FOR HEALTH*A.D.P. JAYATILAKADepartment of Anatomy, University of ZimbabweNEARLY FIFTEEN YEARS ago when I was invited to deliver my inaugural lectureas Professor of Anatomy at the University of Ceylon, now the University ofPeradeniya in Sri Lanka, I spoke on the developments in Anatomy, fromancient to modem times. At the conclusion of my lecture I realized that only ahandful of my largely non-medical audience had appreciated what I had said.Based on this experience, I have today in the selection of my topic 'All forHealth' attempted to democratize the interest in and concern for health.Health is a matter of universal concern and each one of us individually or on acommunity basis is concerned with the attainment and maintenance of health.The concept that needs to be recognized and accepted, and is in fact thecornerstone of my lecture, is the difference between the maintenance ofoptimum health and the curing of disease. While the latter function has becomethe major responsibility of the medical profession, the more important one ofmaintenance of health is the general responsibility of individuals and of societyat large in a collective sense.Cost-effective training of health personnel is a basic and imperative needin developing countries which are grappling with the problems of good healthcare and living standards. These goals in the long term contribute in no smallmeasure to the social and economic future and well-being of these countries.While curative and diagnostic specialists are indispensable, the philosophy of'total health' through all the other components and imputs affecting the healthof populations needs to be incorporated into the training of medical personnelas well as into social and economic development plans.The inter-relation between disease and poverty has been clearlydemonstrated and needs no confirmation. It is, however, paradoxical that eventhe affluent countries of the West such as the U.S.A. have not been able toovercome poverty and consequent disease problems as seen in the ghettos ofthe big cities. It seems that one of the most direct approaches to achieving highhealth standards is the alleviation or elimination of poverty. Once again theaffluent countries of the West, afflicted with serious problems of diseases ofaffluence, such as cardiovascular disease, have proved otherwise. It isappropriate to quote from Ivan Illich's Tools for Conviviality (pp. 3-4):the unwanted hygienic by-products of medicine began to affect entirepopulations rather than just individual men. In rich countries medicine* An inaugural lecture delivered before the University of Zimbabwe on 4 August 1983.15began to sustain the middle-aged until they became decrepit and neededmore doctors and increasingly complex medical tools. In poor countries,thanks to modem medicine, a larger percentage of children began tosurvive into adolescence and more women survived more pregnancies.Populations increased beyond the capacities of their environments and therestraints and efficiencies of their cultures to nurture them. Westerndoctors abused drugs for the treatment of diseases with which nativepopulation had learned to live. As a result they bred new strains of diseasewith which modem treatment, natural immunity, and traditional culturecould not cope. On a world-wide scale, but particularly in the U.S.A.,medical care concentrated on breeding a human stock that was fit only fordomesticated life within an increasingly more costly,man-made, scientifi-cally controlled environment. One of the main speakers at the 1970A[merican] M[edical] Association] convention exhorted her pediatriccolleagues to consider each newborn baby as apatient until the child couldbe certified as healthy. Hospital-born, formula-fed, antibiotic-stuffedchildren thus grow into adults who can breathe the air, eat the food, andsurvive the lifelessness of a modem city, who will breed and raise at almostany cost a generation even more dependent on medicine.In recent times there has been an increasing awareness that preventivehealth-care is preferable to curing disease. Yet most countries spend nearly 75per cent of their health budgets on medical and hospital care rather than onpreventive health-care; and whilst every effort is made to produce moresophisticated cures for disease and millions of dollars invested in drug researchfor chemotherapy, negligible efforts have been directed towards producingbetter standards of health for individuals. At the International Conference onPrimary Health Care held at Alma-Ata in September 1978, a resolution wasmade that the objectives of the world community in the coming decade shouldbe the attainment by all people of the world by the year 2000 of a level of healthenabling them to lead socially and economically productive lives. Thoughnearly five years have lapsed since then, no significant progress has been madein this direction. In fact primary health-care has been replaced by primarymedical care and the emphasis in medical teaching is one of patient care andcure.This approach derives from the early Egyptian and Greek systems onwhich modern Western medicine is based and in which the patient was the centreof medical attention. The physician was essentially required to be a diagnosticianand to carry out a curative function. Beyond this role he contributed very littleto the general welfare of his patients and was unconcerned or unfamiliar withthe disease-causing factors and forces of the patient's environment and life-style.The Eastern system of medicine on the other hand, as exemplified in theAyurveda system, was based on a different and more positive approach tohealth Š that of healthy disease-free living. A system that recognized thetotality of the individual both in terms of the interdependence of physical and16and faculties as well as the inseparability of the individual, eet. The practice of these systems is believed to date back to.;d medical history. Cumston (1926, p.55) and Puschmannrecord the earliest establishment of such hospitals in Sri0 B.C. The ancient system of medicine first established inind Charaka was divided into Rig-Veda, the art of healing,3 science of long life. Ayurveda is still actively practised ina and in Sri Lanka is in the only form of health care availableis.The Ayurveda system is based on the concept of long life through health,and of the body being composed of four elements: Patavi, solidity or cohesion,4po, fluidity; Vayo, motion, mind or gas; and Thejo, heat. The basic bodyiunctions were classified into; Vath, pressure, Pith, metabolism; and Sem,secretion. Health was dependent in the interbalance of these elements andfunctions. The system also incorporated codes for healthy living, includingdietary, socio-cultural and behavioural norms and desiderata. Certain foods. were recommended as healthful while consumption of others was discouraged.Vegetarianism and consumption of dairy products like milk, butter, cheesewere advocated while the drinking of alcohol and smoking were discouraged.These codes included rales of hygiene such as practice relating to the boiling ofdrinking water and disposal of body wastes. This brings to mind Deuteronomy23:12-14 which also gives a record of hygienic disposal of excreta:You shall have a place outside the camp and you shall go out to it, and youshall have a stick with your weapons; and when you sit down outside, youshall dig a hole with it, and turn back and cover your excrement: becausethe Lord your God walks in the midst of your camp to save you,., thereforeyour camp must be holy that He may not see anything indecent among youand turn away from me,in Ayurveda, rales of conduct and social behaviour conducive to goodhealth were laid down. Greed and anger were considered distasteful and stress-promoting, and spiritual activities exalted as a source of serenity and mentalhappiness. Meditation, currently being revived and emulated in Westerncountries for its stress-relieving effects, was recognized as an important activityfor mental and physical health. Eastern religious codes were also cognizant ofthe need for mental and spiritual strength, stability and activity as essentialingredients for physical well-being, The Buddha, who lived over 2,600 years-3go, when asked what was man's greatest blessing, stated quite categorically inPali 'Arogya parama iabha' which means 'Health is the greatest blessing'. Heanther expounded on the 'Mind as the forerunner of all good states Š mind is.znief, mind-made are they. If one speaks or acts with a pure mind, because ofthat happiness follows one even as one's shadow that never leaves,' Thistneory is expressed in another quotation: 'The world is led by mind [thought],i?y mind the world is drawn along': and the development of the mind was seen inBuddha's teachings as the most powerful means of achieving mental andphysical well-being and serenity.The Ayurvedic medical codes included norms of sexual and social behaviourconducive to good health and it is interesting to note that countries such as SriLanka were free of sexually transmitted diseases such as syphilis andgonorrhoea until the invasion by the Portuguese in 1505. Environmentalfactors such as noise and dust were recognized as disease-promoting agents; ahealthy environment was seen as one free of such elements.These principles of the Ayurveda system are also reflected in the ancientChinese traditions of medicine. The basis of these theories was that the bodyconsisted of two components, the Ying and the Yang, and health depended onthe harmonious balance of Ying and Yang. The equivalents of Ying and Yangin modern medicine, in my opinion are probably the sympatheticand parasympathetic components of the autonomic nervous system.It is seen therefore that in ancient Asia the science and practice of medicinewere based on the idea of man as an inseparable component of his totalenvironment, and as a complex of internal forces, both physical and mental,and the harmonious balance on which depended health. Social and religiousexamples of the food and of pure life were provided through the lives of saints,scholars and respected elders in the community whose values and examplewere respected and emulated even by powerful war-lords and kings.How is it possible to revive these approaches and principles of health-careand training and apply them in the modern-day context?Nearly 80 - 85 per cent of the estimated populations of developing countrieslive in rural areas and they do not have adequate nutrition or safe drinkingwater; they do 'not have adequate housing, education, land-ownership,sanitation, meaningful employment or health-care services. This pattern isseen in the developing countries of Africa, Asia and Latin America. Ruralhealth cannot be looked at without reference to the other inter-related ruralproblems. For instance malnutrition cannot be solved without reference toland hunger, lack of water for irrigation, economic factors, rural technology,education and the other amenities available to the urban population. Oftengovernmental agencies are incapable of providing the necessary relief to therural areas as the officers responsible for all such schemes and measures arenot sufficiently motivated or dedicated. These officers are often ignorant of theway of rural life, the customs, beliefs, superstitions and the generalsociological and cultural patterns that are part and parcel of the rural setting. Itis the view of Ammundsen and her colleagues (1973, pp. 104, 106) thatthe differences between urban and rural societies, between regional andethnic groups, and between persons with different ways of living andvalues, make it essential that the interface between the consumer [ofhealth] and the health service be influenced by the consumer and that theaccepted pattern serve the needs of both the health service and theconsumer . . . [for the] causes for dissatisfaction of population about their18health services can be summarized as a failure to meet the expectationsof the population, an inability of health services to deliver a level ofnational coverage adequate to meet the demands and the changing needsof different societies, a wide gap [which is not closing! in health statusbetween countries, and between different groups within, the countries,rapidly rising costs without a visible and meaningful improvement inservice, and a feeling of helplessness on the part of the consumer whofeels [rightly or wrongly) that the health services and the personnel withinthem are progressing along an uncontrollable path of their own whichmay be satisfying to the health professions but which is not what iswanted by the consumers.At this stage it is worth looking at some facts and figures about the situationin the world in general and in Zimbabwe in particular. According to a W.H.O.lecturer (Alagiah. 1982, pp. 3-4):Every year 500 million people (1/8 of the world's population) fallvictims to water related diseases. Every single day 30,000 people (half ofthem infants) die of these diseases. 50% of hospital beds are occupied bypatients suffering from these diseases. It is estimated that 80% of man'sillnesses, in impoverished developing countries, is water related.Illness and death are not all the sufferings caused by bad water or the lackof it. Every single day hundreds of millions of people in developingcountries waste vast amounts of time and energy carrying heavy loads ofwater over long distances.Women, and children bear the brant of it. For tens of millions of childrenthe day starts with a long difficult walk to fetch water... [before j they dragthemselves to school... In... Upper Volta, mothers daily walk for two orthree hours to stagnant water holes or the river, 12 kilometers f aj way, andreturn with 25 kilos of water on their heads. In the process they bum up...1/3 [of] their daily average food intake.If all this time and energy , . . could be saved, by the provision of easilyaccessible water, what great benefits could accrue to the community. Thewomen could engage in farming, cottage industries etc. and the childrencould concentrate on their studies and grow up to be more useful citizens.Sanitation is a concomitant feature of water supply. Bad sanitation is oftenthe cause of unsafe water supplies. Likewise, provision of plentiful watersupply could lead itself to sanitation problems ... [for] bad sanitation is thecause of many helminthic diseases.In view of the debilitation that such diseases cause among the rural massesof tropical and semi-tropical areas, it is not surprising that Dr Halfdan Mahler,the Director-General of W.H.O., in launching the International Drinking-Water Supply and Sanitation Decade at a special seession of the UnitedNations General Assembly in 1980 said 'Because of what it will imply, both inplanning and results, the number of water taps per 1,000 persons will become abetter indicator of health than the number of hospital beds* (W.H.O., 1981a,p.26). In order to achieve this improvement, however, much capital isrequired. Approximately U.S.$30,000 million would be needed annually overa ten-year period. By conservative standards a sum of U.S.$80 million isneeded every day. Yet U.S.$240 million are burnt up as cigarettes andU.S.$10 million on tranquilizers daily, lhe dally spending for militarypurposes Is U.S.$1,400 million. Thus, If half these amounts are spent onImproving water supplies and sanitation In developing countries, the citizens ofthese countries could look to a brighter, happier and more hopeful future(Alagiafa, 1982, p.5).But there are many other health problems. In a statement published by theW.H.O. In 1981 It is said:Nearly 1,000 million people are trapped In the vicious circle of poverty,malnutrition, disease and despair that saps their energy, reduces theirwork capacity and limits their ability to plan for the future. For the mostpart they live in the rural areas and urban slums of developing countries.In the developed countries Infant mortality is between 10-20 per thousandand In developing countries It is 100-200 per thousand. Of every thousandchildren bom into poverty In the least developed countries, 200idie withina year, 100 die before the age of 5 years and only 500 survive up to 40years. Most deaths are from infections and parasitic diseases. Diarrhoea!diseases caused by human faecal contamination of soil, food and watercause high mortality in the population. Disease caused by Insects and theirvectors rate high; in Africa alone at least one million people die each yearfrom malaria. An estimated 200 million people suffer from schlstosomlasls,aod onchocerciasis or 'river blindness' causes blindness in a fifth of theadult population in some regions of Africa. Undenratritloe is a tragicresult of poverty and land hunger, and in developing countries only twothirds of energy requirements, In kilocalori.es daily per person, are obtained.Illiteracy and lack of education play a major role in causing Ill-health.Some 900 million adults In developing countries are unable to read orwrite and only 4 out of 10 complete 3 years of primary school (W.H.O.,1981b, p. 4).Such problems are also aggravated by the shortage of medical manpowerin these countries:To Illustrate the disparities among countries, in the least developedcountries one health worker of all categories, Including tradtional practi-tioners, has to serve on the average 2,400 people, in the other developingcountries 500 people, and in the developed countries 130 people. As formedical personnel, In the least developed countries there is one doctor foran average of 17,000 people, in the other developing countries one for2,700 people, and In the developed countries one for 520 people (W.H.O.,1981b, p.4).Many of these problems are suffered by Zimbabwe and in the reportPlanning for Equity in Health, such inequalities are listed and nutritionaldeficiency in children is highlighted. In surveys undertaken by the Ministry ofHealth it has been shown that nearly one third of children between one and fiveyears of age in communal areas showed definite evidence of malnutrition(Zimbabwe, 1981b, p.6), A study by Chikanza and his colleagues in our ownFaculty of Medicine (1981, p. 89) showed that undemutrition was prevalent inchildren, of under five years of age, of employees of farm-owners. 'In a foodexporting country this situation is a national disgrace. It reflects the unequal20ownership of the means of agricultural production, notably of good land.' Evenin Harare, a City Health Department Survey in 1980 of 33,000 childrenshowed that 25 per cent showed evidence of undemutrition (Zimbabwe,1981b, p. 6), Infections play an enormous role in causing disease and deathamongst the young. Among the most important causes of child mortality arediarrhoea, pneumonia, whooping cough, measles, tetanus of the newborn,malaria and tuberculosis. All these are preventable and are related to aninadequate supply of safe water and an inadequate excreta-disposal system.The racial distribution of diseases among the White and Black population hasan incidence ratio of 1:9. These figures speak for themselves.The Report of the Commission of Inquiry into Incomes, Prices andConditions of Service showed that in i 979 the average total income of the non-African worker was well over $8,500 per year while urban Blacks in formalemployment earned an average of Z$ 1,150 (both figures underestimate familyincome where there is more than one wage-earner). The average income ofpeasant farmers was estimated to be Z$220 per year (Zimbabwe, 1981a,p. 77), In the same period the mean income of a private medical specialist wasestimated at Z$40,f)G0 per year (Zimbabwe, 1981b, p. 39 and Table 14).Thus it is not surprising that a clear inverse relationship has been establishedbetween family income and infant mortality in Zimbabwe (ibid.).In a 1962 survey of the 19.5 million acres of land most suitable forintensive cultivation, 77 per cent was allocated to the Whites (Zimbabwe, 1981b,p. 11), It is said that when the early White men came to Zimbabwe they readthe Bible and the Africans owned the land. Now the Africans read the Bibleand the White men own the land. In education there are similar disparities,with eighteen times as many Whites as Blacks, proportionately, receivingsecondary education (ibid., p. 12).In 1980/81 the Ministry of Health's budgeted expenditure was Z$77,4miliu u i ,.resenting 65 per cent of national expenditure on health care andabcm 5 K" cent of total government expenditure. Of this budget 88 per centwas <^>. >.i >pital care, 8 per cent formed the preveoiive services vote, includinga grant to the Family Planning Association, The following table drawn fromthe Reports of the Secretary for Health for 1979 and 1980 (Zimbabwe, 1980,Table 2; and 1982, Table 2) show fifteen diseases as causing highest mortality;and it is obvious from these figures that most of the diseases causing mortalityare preventable if adequate and proper health measures are available.The Primary Health Care Conference at Alma-Ata in 1978 agreed thatthe promotion of food supply and proper nutrition, an adequate supply of safewater and basic sanitation, maternal and child health care including family-planning, immunization against the major infectious diseases, prevention andcontrol of locally endemic diseases, and the appropriate treatment of common.diseases and injuries and provision of essential drags would provide primaryhealth-care. This means the improvement and development of agriculture,21TableMOST FREQUENT CAUSES OF DEATH IN ZIMBABWECauseDiseases of respiratory systemViral diseases (measles, hepatitis, polio)Diseases of perinatal periodIntestinal infectious diseasesTransport accidentsHomicideMalignanciesNutritional deficienciesCirculatory diseasesDiseases of digestive system including cirrhosisTuberculosisBacterial diseaseCerebrovascular diseaseOther accidentsArthropod-borne (malaria)Number of1979'2 1812 0641 5691 31188886640085168877339868667051!165Deaths19802 4411 4302 2871 2271 2451 509874864942819488421648630357animal husbandry, food industry, education, housing, public works ant!communications. To achieve these objectives, responsibility for the health ofthe people cannot lie only with health ministry personnel or with the medica'profession. It is obvious that many diseases are caused by inadequate or pooiquality water. The provision of such water is the responsibility of theappropriate ministry of a government. Similarly in cases of malnutrition theanswer to the solution of the problem lies outside the province of healthpersonnel. The proper development of agriculture, and the marketing ant.)availability of essential food at low cost are functions which have to becarefully promoted and monitored by the government. Diseases caused bypoor housing and sanitation are common in all Third World countries and withthe increase of population the situation is getting worse. Returning patients tcthe same environment that caused the disease only makes them come backagain and again for treatment, at tremendous cost.The aim of promoting health and also providing medical care cannot lieonly with the medical profession. The establishment of a health authority withpowers of co-ordinating health promotion and curative services is essentialUnder the health authority there should be division of responsibilities betweenthose actively engaged in promoting health and those promoting curative work.with close integration and monitoring between the two. The promoters ofhealth should be responsible for providing safe water, housing, sanitation.education, adequate nutrition, agriculture and health education, and for job-creation. The curative group should diagnose and treat disease, educate forhealth, undertake immunization procedures, cany outepidemiological studieswhen diseases are reported and inform the health promoters so that correctaction may be taken, undertake family-planning procedures, and providecheap essential drugs. The medical personnel must establish the variousparameters for health in each population group, such as height, weight, bloodcount and other norms for that particular country, and give advice on whatfoods must be eaten in order to achieve those norms.The success or failure of such a programme will depend on theimplementation of the political philosophy of the government in a country. AsEmery (1974, pp. 40-5) has noted, in China during the Cultural Revolutionthere was severe criticism of public health work because it was serving onlyfifteen per cent of the population. The peasants could not get treatment, andthey had no doctors and no medicine. The Ministry of Health was not thepeople's Ministry of Health; it had become 'the towns' and mandarins'Ministry of Health',The late Chairman Mao then redistributed a large proportion of the urbanhealth personnel to the rural areas and created mobile medical teams frommedical schools and hospitals to visit rural areas to further strengthen thehealth services by demonstration, teaching and in-service training. This effortresulted in the training of large numbers of auxiliary personnel Š the 'barefootdoctors'. Emery outlines the nature and functions of this 'barefoot doctor' inChina and the integration of traditional and preventative and curativefunctions of modem medicine. The overall ratio in 1973 of barefoot doctorswas 1 to 650 people, and by December 1973 a total of 1,220,000 had beentrained. The 'barefoot doctors' work predominantly in rural China where75-80 per cent of the population lives.In Third World countries where populations are at bursting point themedical personnel turaed out by the medical schools never hope to deliverreasonable medical care except to a small portion of the population. Inaddition to the medical graduates, other categories of health personnel, withless training, are necessary to bridge the deficit. In Zimbabwe in 1980,according to the report of the Secretary of Health (Zimbabwe, 1982, p. 63),there were, to cater to an estimated population of 7,360,000:DoctorsDentistsChemistsGeneral NursesMidwivesMaternity NursesMedical AssistantsEnrolled NursesLater statistics are not available.1 1481583544 65223511392 897191but it hobvious that, even if thesenumbers of personnel are doubled, medical care could never reach the entirepopulation which, it must be remembered, increases each year. In many ThirdWorld countries attempts to increase the number of medical schools, andsubsequently the intake of students, have not Improved the situationappreciably. In Sri Lanka, for example, 120 medical graduates graduatedyearly from Colombo, up to 1961, when the population was under10,000,000.In 1962 a second medical school was opened in Peradeniy a and from 1968another 120 graduated yearly. By 1970 because of deteriorating economicconditions, poor facilities and poor salaries, many medical graduates started toemigrate to the developed countries and in an eight-year period nearly 2?QG0medical graduates had emigrated. In 1978 the government opened two newmedical schools, one in Galle and one in Jaffna, with a combined additionalintake of 175 students due to graduate in 1933. Yet, in 1982 there were 800medical institutions without any medical officers, In 1981, a fifth medicalschool, privately ran, was opened with an intake of 100.In 1974. the Ministries of Health and Education entrusted roe, as Dean ofthe Medical School, with the task of carrying out a feasibility study andformulating plans to train medical personnel within a shorter period of trainingthan that of the conventional medical programme, The cause of emigration ofthe five-year doctor was studied and it became abundantly dear that the maincauses for doctors leaving Sri Lanka on appointment to rural areas were; (i)poor facilities prevalent in the rural hospitals which produced jobdissatisfaction; (ii) lack of proper housing; (Hi) lack of proper schooling forchildren; (iv) poor salaries; (v) inability to purchase essential items of food;(vi) lack of social contacts; (vii) poor roads and transport facilities; and (viii)lack of opportunities for further education and personal advancement Asurvey was undertaken to ascertain the conditions of the major provincialhospitals and the available staff to train medical personnel OE a course of twoand a half years' duration, and it was foiled that the provincial hospitals couldtrain such personnel in each hospital provided that the numbers were small,A committee was then set up under the Medical Education Unit atPeradeniya to draw up objectives for the course and a curriculum. It was thedecision of the committee that the curriculum, should not be merely an abridgedversion of the five-year curriculum of the medical schools which basicallyfollowed the British tradition but be geared to realistic needs and goals. Thesemedical personnel were to complete their course in two and a half years with asix-month internship. The method of selection was also different in that theywere selected primarily from rural areas and from among those who showedother all-round qualities besides mere academic achievement. It was also theintention of the committee to see that these medical personnel would go backand serve in the areas from where they had been selected.The selection process was different in that promising young people werenominated by the schools, rural societies ~' HU-, jr\: \;i -m-noi." on^eilocal Member of Parliament, who in tuir ov. .v. 'r,rtx-.. -t-* c .iffne^o nomineesfrom the district and forwarded their n.r., - * A: Vf'ti-'-ir . Health. Theperformance at the G.C.E, 'O'-level was g<\ r . :> > % Ł ^ c; ^ ibrmance at'A'-level. They were interviewed for speafk quahu.. -* ni»ieiul HealthMinistry and the University. The selected candidates \\*;: «Ł seated innumbers of 30 to 50 to each of the pro\«''i w- h<-.*,p.«.—,-Ł ,. v.. w>. practicalteaching was conducted by Health Minis irvMArica. ^'licc;- *> iis. universitiesmonitored the progress of the course.The desired characteristics of the end-product were clearly stated.Emphasis was laid oe health promotion and preventive medicine with a limitedlist of pathological states that had to be treated. Family-planning programmes,maternal and child-health care, immunization, health education and goodrelationships with rural people were stressed. The students were taught how toadminister a small rural hospital called a peripheral unit. The other greatdifference from the M.B.B.S. course was that these students had to function ina health team, and this aspect was stressed from the beginning.Basic sciences were not taught as anatomy, physiology and biochemistrybut as structure and function of body systems, by the same teacher with verylittle detail. They then learned clinical medicine in the hospital but practised itunder supervision in the field. Sociology, behavioural science and publichealth were taught for two years.After a six-month period of internship the health worker was posted to therural areas, taking charge of a small peripheral unit. This programme wasfound to be quite successful. These health worker's were called AssistantSeveral medical consultants have confirmed this view. In fact many consultantspreferred Assistant Medical Practitioners as interns to the five-year-trainedM.B.B.S. graduate. Perhaps the knowledge of their limitations and the need toprove their leadership capabilities gave the Assistant Medical Practitioners ahigher level of motivation and dedication. They were also aware that, if theyshowed a good record of work, the chances were that they would be registeredas Medical Practitioners after a ten-year period. Nevertheless the medicalgraduates and the Assistant Medical Practitioners taken together could stillnot provide adequate medical care to the entire population.In 1973, Abeysekera, Chandraraj and Simeonov studied the dataconcerning Ayurvedic or indigenous practitioners in Sri Lanka, of whom therewere 10,806 registered as practitioners; and these authors estimate that theAyurvedic sector met 70 per cent of the demands of the population. Inrecognition of this the University of Colombo established an Institute ofAyurvedic Medicine in 1974 and now this institute is a fully fledged faculty.The stoderits were taught basic sciences but the pharmacopoeia was different.From as early as the fifth century B.C. Ayurvedic medicine flourished in SriLanka. Puschmann relates that as early as the fifth century B.C. KingPandukabhaya had a hospital built at his residence and that King Buddhadasain the fourth century A.D. arranged sanitary organizations for the wholecountry. Even in colonial times Ayurvedic clinics and hospitals were built.After independence from the British, in 1948, the facilities in these hospitalswere extended by every successive government. An Ayurvedic researchinstitute was established as early as 1958. Ayurvedic medicine is firmlyestablished in India and, according to Fendall (1982), the combination oftraditional healing and modern medicine appears to be most promising andappropriate solution for health-care problems facing the developing countries.In spite of the presence of a large number of Ayurvedic practitioners andpractitioners of modern medicine there were still many people who had noaccess to medical care. With the inspiration derived from the Chinese'barefoot' scheme, a scheme was designed to train young people belonging to avoluntary organization, the Sarvodaya Movement, to work with governmenthealth personnel to improve the quality of health in the rural areas. TheSarvodaya Movement is a voluntary organization engaged in trying to improveall aspects of community life, including health-care based on the existingBuddhist philosophy and traditions prevalent in the country. The traineeyouths formed a critical human resource who were emotionally committed tobringing about a change in society, and they were selected by the village eldersfor their motivation, dedication and leadership qualities.This is a good example of what was recommended by the FourthCommonwealth Health Ministers' Conference held in Colombo in November1974:The conference recognised that in many instances governments had attheir disposal the services of non-governmental organizations, voluntaryagencies and private individuals capable of materially supplementing andcomplementing their own efforts. The co-ordination of activities under-taken by non-official bodies and individuals with official programmes forimplementing national health planning objectives would greatly improvethe delivery of health care in rural areas... and that the community shouldparticipate at all levels of the planning and decision-making processes ifinvolved in establishing the rural health delivery system (CommonwealthSecretariat, 1974, pp. 18-19).Similarly the Director General of the W.H.O., Dr Halfdan Mahler, saysthat teachers, community workers, social workers, and civic and religiousleaders should be involved in health-care. New training programmes mustinclude the teaching of those skills which help individuals and communities toformulate their problems and to choose the right solutions, as well as topromote self-care and self-reliance. Health-education is essential for ensuringappropriate self-care.The rationale for the Sarvodaya course was that in the rural areas of SriLanka there was a dearth of the resources necessary to ensure that the health-care that the people received was efficient. The greatest deficit is in trained26health manpower. The need for health-care in these areas is forever increasing.The situation of great demand in the face of meagre resources had the resultthat people seek health-care from unqualified practitioners, or resign themselvesto traditional home remedies, both of which are often deleterious to health. Fourbroad units were identified in the youth-training curriculum, and each unitcontains a set of objectives, learning experience and evaluation:First Unit: Curative health to the individual: The trainees learnt how torender initial emergency care to patients and to recognize the common featuresof infections, malnutrition, symptoms of other diseases and wounds. Thecommon rural belief that devils were the cause of disease was rationalized byshowing the people that the bacteria, parasites and small worms under themicroscope were the 'devils'. Simple 'structure and functions' lectures on thehuman body were given with the aid of charts. Demonstrations were given onfirst aid. The trainees were evaluated by making them demonstrate practicalprocedures. Simple treatments, of wounds for example, were evaluated.Second Unit: Preventive health care to the individual: The trainees had toexplain how infections are spread. They had to advise individuals on properdisposal of faeces, on personal hygiene, proper storage of food, and watersterilization by boiling. Immunization procedures were taught, and thetrainees also had to prepare lectures on health education and nutrition.Third Unit: Health care to the family unit: The trainees had to advise pregnantmothers and parents about nutrition, give advice regarding immunization andcarry out immunization procedures. They also were to advise on methodsavailable for family planning and to collect data on the socio-economic statusof, and illnesses in, the family.Fourth Unit: Health care to the community: The trainees had to work withhealth teams and investigate outbreaks of illness in the community and identifypotential sources of dissemination, collect data, immunize and assist in familyplanning procedures. They also had to direct the people to National HealthProgrammes such as campaigns against tuberculosis, malaria or filaria, and tostimulate the community to work for the benefit of the whole rather than that ofthe individual.All these units were evaluated by pen and paper and also tested by thedemonstration of skills by the trainees.The main idea behind this scheme was that those who were trained wereinvolved in socio-economic development on a voluntary basis and as such theywere Mghly motivated and dedicated, and relieved the health personnel of theirburden. These trainees in turn train people engaged in full-time work infactories, on farms, in various government and private institutions, and invillage communities. By this method the people are mobilized to look aftertheir own health at a primary level with very little cost to the government orthemselves.This scheme appears to work well in Sri Lanka which enjoys a literacy rateof over 90 per cent. The implementation of health care Is no longer theprerogative of health ministry personnel, It is the Intention to make everycitizen a health worker. Modifications of this scheme may be applied to otherdeveloping countries and in fact some countries have health-workers trained atthis level. The main emphasis is that health must be actively pursued and it canbe achieved only with the participation of all the citizens of a country. Health-education, and above all, education as a whole, is vital. In countries where thelevel of education is high, the health of the people is also good,It is necessary, therefore, to train several levels of health personnel forcurative work and these categories must be able to treat diseases that cannot becontrolled or eradicated by health promotion. It is essential that data becollected on the prevalence of disease and on the available personnel to meetthese health needs and demands. The total resources in terms of personnel,money and other factors must be correctly ascertained and in order to do this aplanning unit is essential. This should be located either in the Ministry ofHealth or in the Faculty of Medicine to collect epidemiological, sociologicaland other data and monitor resources, and it should plan for five-year or tenŽyear projections.Data necessary to generate educational objectives according to Guilbert(1977, p. 120) are; health needs, demands and resources of society; services tothe patient; service to the community; the profession itself; the students;progress in sciences ; and the scientific method. Once these are clearlyestablished it is the duty of those institutions training health personnel to statetheir institutional objectives clearly so that the competencies and skills of the'end-product' can be clearly defined; whether this "end product* is a doctor,dentist, nurse, midwife of of any other health category. According to Guilbert(1977,'p. 105):The institutional objectives of a faculty of medicine, for example, are,they say, axiomatic: 'We train doctors of international quality. It is notnecessary to develop the description, any further; medicine is universal,5However, when we try to get the teachers to define a little more fully whatthey are talking about we see how wide and fundamental the divergenciesare as soon as we leave the sfjfaere of generalities. The conflicts betweenfundamentalists and clinicians, between advocates of preventive and ofcurative medicine, are the result of those divergencies, This conflictbecomes acute during the periodic curriculum reforms.Institutional objectives have been defined for the Faculty of Medicine inthe University of Zimbabwe but unfortunately they are not based on dataobtained from epidemiological or sociological data. They have been based onimpressions of individual academics. Educational goals are usually defined byusing behavioural terms corresponding to the tasks to be accomplished. Theobjectives must indicate what the graduates of a given institution should beable to do at the end of their period of training that they were not able to dobefore. These are also called 'competency objectives'.Educational objectives are classified by Guilbert (1977, p. 119) as: (1)Institutional: (2) Intermediate (when based on institutional objectives thedepartment draws broad objectives); and (3) Specific (short specific objectivesrelating to a learning unit). The institutional objectives are drawn up bymembers of the faculty or the institution and intermediate and specificobjectives are drawn up by personnel in each department. Well-constructedinstitutional objectives are the foundation of a relevant programme. Allobjectives can be divided according to the sphere of intellectual activity towhich they belong: the cognitive domain (knowledge); the psychomotorydomain (skills); and the affective domain (attitudes) (Guilbert., p. 152). Thisclassification facilitates an analysis of the learning process and helps teachersto make educational choices. The aim of education is to bring about anexpected change In the behaviour of the student in the course of a given period(Guilbert, 1977, p. 207), and the function of the teacher is to facilitate thelearning process. The qualities of the specific educational objective are evidentwhen they are relevant, logical, unequivocal, feasible, observable andmeasurable. Behaviour must be spelt out in terms of verbs of action, such as'to write', 'to identify', 'to differentiate', 'to solve', 'to list', 'to construct',.' tocompare', and'to contrast'. According to Guilbert (1977, p. 143),'Relevanceis the essential quality of educational objectives. Objectives which have everyquality except relevance are potentially dangerous,' Taxonomy is a hierachicalclassification in a given field, and according to Guilbert (1977, p. 151),'Taxonomies in the field of education provide a classification of variousinstructional objectives, at suitable levels, in given spheres,'In the cognitive domain the taxonomic consists of: (1) recall of facts; (2)interpretation of data; and (3) problem sol Ł — * * Ł the psychomotory domain itconsists of (1) imitation; (2) control; aru * .utomatism. In the affectivedomain it consists of (1) receiving (Ł> -riding; (2) responding; (3)internalization-valuing. According to R.F. Mager (as quoted by Guilbert,1977, p. 171), 'If you give a learner a copy of Ms learning objectives you maynot have to do much else.' As stated earlier, the purpose of teaching is tofacilitate learning so that there are interactions between teacher and thestudent to bring about expected changes in behaviour of the student.According to Guiibert (1977, p, 208) the purpose of teaching is to helpstudents to: (1) acquire, retain an be able to use knowledge; (2) understand,analyse, synthetize and evaluate; (3) achieve skills; (4) establish habits; and(5) develop attitudes. According to G.E. Miller (as quoted by Guilbert, 1977,p, 210), 'Teaching methods which place the student in an active situation forlearning are more likely to be effective than those which do not,' It is the29contention of many academics in many medical schools that the graduates oftoday do not have the proper attitudes to health and to the care of patients.Faculties of medicine have attempted to change the curriculum in the hope thatattitudes would change, but this has not necessarily happened.There is a great reluctance on the part of medical graduates to work in ruralareas; the reasons for this have been mentioned above. The curriculum plannerfeels that, if medical students are made to spend a good deal of time in ruralareas from the first year onwards, a change in attitude may be expected. Thepremise that medical students are not aware of rural conditions and thus shouldbe subjected to continuous rural exposure is not necessarily true. For example,in Zimbabwe the new curriculum planners hope to send medical students to do'clinical attachments5 in rural hospitals in the hope that the attitude of theZimbabwe medical graduate would change. Some even claim that medicalstudents enjoy these rural clinical attachments. This may be so for Europeanstudents who come from urban schools but the rural Zimbabwean medicalstudent may well wish to forget the harsh reality of the environment from whichhe came. In fact the government of Sri Lanka, in order to help rural students tostudy medicine, selected the majority of students from rural districts. Thesewere sent to do clinical medicine in rural hospitals in order to bring aboutcorrect attitudes. A careful study of these students compared with those fromurban districts showed that those from rural districts refused to work in ruralhospitals after graduation, and there was no significant difference in attitudesbetween the two groups. The reasons were obvious. Modem medicinecontinued to be practised in urban hospitals while the rural hospitals wereneglected and without facilities.Students very often imitate the attitudes of their teachers. In Sri Lanka theclinical teachers did not facilitate learning; they were hardly seen in theteaching hospitals because they were always working in private hospitals andnursing homes. Even when they did come to the teaching hospitals, they paidmore attention to those patients who had consulted them privately than thosewho could not afford to do so. Also, medical consultants and academics live inrelative luxury in the cities and students often wish to imitate these life styles.Small wonder then that graduates do not wish to serve in rural areas where theymay be forced to lead an almost ascetic life. It is difficult to hide corruptmalpractices adopted by senior doctors; and young doctors in turn becamecallous and indifferent to their patients. In certain countries, doctors chargetheir colleagues a fee, proving that in this case, dog can eat dog. When aspecialist is consulted the first question he asks is not what the patient'scomplaint is but what type of medical insurance the patient has. Not all doctorsare of this sort and several do not claim their fees from medical insurance fortreating other doctors.I firmly believe, therefore, that not much good would come from ruralattachment by medical students unless the teachers change their attitude30towards people and to their own life styles. One often hears of the criteria thatare suggested for promotion of a teacher. They include teaching, research anduniversity public service. A teacher may have all these; but, if his attitudes tostudents and patients are negative, then he is a bad influence on his students.Should not an attempt be made to impart the correct attitudes to teachers?Attitudes are leamt from example and it is the responsibility for the teacher toset that example. A teacher's attitudes depend on a whole host of factors,including a philosophy of his own making, so it is important that not onlybehavioural science and sociology by taught in the medical curriculum, butphilosophy as well. It is worth noting that in countries such as Norwayphilosophy is a basic qualifying course for undergraduate study; I believe that amoral philosophy is absolutely essential for the happiness of society. Nothingcomes to me more clearly than the message of the Buddha for the moulding ofattitudes.The Buddha spoke of the divinity found within oneself; he called this the"Sathara Brahma Viharana' or the Tour Divine Qualities', He explained themas: (i) Metta (Loving Kindness): (2) Karana (Compassion); (3) Muditha(Altruistic Joy); and (4) Upekkha (Equanimity). Loving kindness, the Buddhasaid, should be practised by all human beings. One must spread lovingkindness to all living beings in the same way one does to one's near and dear. Inthis way the suffering and pain of others should generate feelings of lovingkindness; and, with the establishment of loving kindness, compassion mustensue. When compassion arises one must be motivated to be of service to thosein pain or in hunger. When pain and hunger are relieved and when lovingkindness and compassion are actively pursued there arises in one the quality ofaltruistic or selfless joy in the well-being of others. The fourth quality isequanimity which is calmness of mind. This means that one should neither bemade ecstatic by being praised nor be made dejected by being blamed.The Buddha also spoke of group behaviour and enunciated the fourprinciples of group behaviour which he called 'Chatu Vastu Sangraha'. Theyare: (1) Dane (Sharing or Generosity); (2) Priya Vachana (Pleasant Speech);(3) Artha Charya (Constructive Action); and (4) Samaeathvatha (Equality inthe Eyes of the Law).Sharing or generosity is a virtue practised by many people in Buddhistcountries. By the act of sharing or generosity one tends to overcome greed:sharing of food, sharing wealth, sharing of ownership of land, sharing ofknowledge, sharing of experience and skills and sharing of power. In thematerialistic world of today this is difficult to practise. This is the basis ofsocialism which the Buddha preached 2,600 years ago but which is todaypractised hardly anywhere. All the trials and tribulations which have occuredall over the world have been because of the refusal by some to share power. Sosharing and generosity are essential for human happiness.31Pleasant speech Is a sine qua non for all categories of health personnel.Speech is one of man's greatest evolutionary accomplishments and is a majortool of communication. It is a powerful force that can cause active constructionand massive destruction. Everyone likes a pleasantly spoken person anddislikes those who are rude, insolent and vulgar. Speech is used in educationand in the moulding of attitudes. Use of "bad' forms of speech reflectsthe mental attitude of 'bad5 people, while pleasant speech is effective andproduces positive attitudes. If one speaks kindly to a person the chances arethat the other person will react favourably and positively. Pleasant speech isessential for all categories of teachers of health personnel in order that thispositive attitude can become ingrained in ail health personnel. When a patientis ill there is no better drag than pleasant speech. Talking ill of people should beavoided.Constructive action is preferable to destructive action. Many people wastetime chatting and gossiping and it has been estimated that 80 per cent of time ina conversation between people is spent on speaking ill about someone who isnot present. Because of inferiority or fear of non-recognition people oftenbelittle ideas or actions of other people by devious schemes. This is notconducive to harmonious living. Only when one's daily actions bring aboutpeace and happiness to others could these be acknowledged as constructiveaction. To act together, in unison, for the betterment of many, the Buddha says,is constructive action.Equality in the eyes of the Jaw is something that must be stressed. If there isa law in a group or in a society then that law must apply equally from thehighest to the lowest in that group or society. In some societies laws exist only forthe menials and not for those who are responsible for drafting the law. Theflouting of equality in the eyes of the law has led to corruption, strife andnepotism in the so called emergent nations of the Third World, The adherenceof a society to real equality gives tremendous confidence to all members of thegroup.Attitudes are often moulded by influential people in a society, especiallypoliticians, A form of behaviour exhibited by a powerful group in a society isoften imitated by others. If the behaviour imitated is wholesome then it has awholesome effect on society, Similarly, the attitudes of the doctor may bemoulded by the attitude of politicians and transformed to the medicinepractised by them. If the politicians have confidence in the local doctors, withspecial emphasis on rural medicine, then the whole country would have faith inthe new system. If the politicians have confidence in the local doctors, withspecial emphasis on rural medicine, then the whole country would have faith inthe new system. If the politician seeks treatment in a Western country then themorale of the rural medicine scheme would fall, especially if the treatmentwere for a condition that could have very well been treated in his own country.No wonder that so many doctors migrate from developing countries to placesthat practise esoteric medicine, in spite of the great emphasis given to ruralmedicine in their own curriculum.The attitude of teachers is of paramount importance in imparting correctattitudes to students. Teachers must not only be highly trained in theirspeciality but also be aware of and conversant with new methods ineducational technology.Attempts have been made to evaluate the qualities of a teacher. In someinstances this is done by peers which is entirely a subjective assessment.Student evaluation of teachers has been adopted in some universities but hereagain there is personal bias and extremely subjective judgement. If the teacheris to facilitate learning and learning is a change of behaviour of the student, thiscould be evaluated by more objective methods. The teacher could draw up a setof behavioural objectives that students are expected to accomplish in a givencourse. The students could then be pretested and their behaviour assessed; theteacher then undertakes the segment of learning either by lectures, tutorials,demonstrations and practical classes. At the end of the learning segment thestudents are subjected to a post-test. From the difference in standard scoresbetween the post-test and the pre-test it is possible to evaluate the teachingcompetence of the teacher in an objective manner.Evaluation or testing is a measurement to find out the change of behaviour'in a learning situation,. Two types of student evaluation are available: (i)formative or diagnostic evaluation; and (ii) summative or certifying evaluation.The aim of formative evaluation is to inform the student on the amount oflearning he has achieved and is not used as a certification process. Summativeevaluation is a decision by which a student would end a unit or course or passto the following year. The aim of evaluation is to provide feedback to thestudent and the teacher and for protection of society. According to Guilbert{1977, p.335) there should be validity, reliability, objectivity and relevance.Validity is the degree of accuracy with which the instrument measures what itis constructed to measure. Reliability is the consistency with which aninstrument measures a given variable. Objectivity is the degree of concordancebetween the judgements of independent and competent examiners as to whatconstitutes a good answer to each of the elements of a measuring instrument.Relevance is the extent to which criteria, established for selecting questions sothat they conform to the aims of the measuring instrument, are respected.The methods of evaluation available in medical education consist ofwritten papers, practical tests, clinical assessment and orals. The qualities of atest should be directly related to educational objectives, realistic and practical,important and useful, complete but brief, and precise and clear. There areseveral types of written examination: essays, short open-answer questions,true/false items, and multiple-choice questions. Practical tests could beconducted to test psychomotor skills such as the ability to do a blood count,perform a test for cranial nerves and do spot or recognition tests. In clinicaltests, attitudes could also be evaluated, such as the relationship with, and themethod of examining a patient. Oral examinations are a common feature inmedical schools that follow the British tradition. I wish to dwell a little on thisas there are conflicting opinions regarding the use of the oral in evaluation. Theadvantages are that it:provides personal contact with the candidate;has flexibility in assessment as the examiner can vary questions dependingon the responses received;makes it possible to question the student as to how he arrived at theanswer; andallows two examiners to assess the student at the same time.The disadvantages of the oral are that it:lacks standardization;lacks objectivity,carries the possibility of abuse of the personal contact;lacks adequately trained staff to administer the examination; andis excessively expensive in professional time in relation to the informationit yields.In most enlightened medical schools the weightage given to the oral isextremely low.Another important aspect of medical education is not to overemphasizethe importance of one's own subject or discipline. For instance, Anatomycannot be taught in isolation from other disciplines. Anatomy is but a mere cogin the machine of medical education. The purpose of Anatomy is to provide ascientific basis in the understanding of clinical medicine and its application. Itmust cater to the requirements of clinical medicine and it is imperative that theclinical disciplines must lucidly state what their objectives are. It is only thenthat the pre-clinical disciplines can provide any meaningful instruction in themedical curriculum. Carefully planned integrated or co-ordinated coursesmust be drawn up to cater to the needs of the clinical disciplines. 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