A recent World Health Organization report on the state of health practitioners in the Middle East suggests that the region now has a satisfactory number of physicians; some countries even have an excess. Yet health, as measured by standard indicators such as infant mortality, is hardly satisfactory. The report suggests that large numbers of physicians may not, in fact, have a positive effect on health. [1] In recent years, a small number of medical educators in the Middle East have become concerned about the persisting poor health among people in their countries and the questionable appropriateness of medical care. They have attributed this state of affairs to the training offered in medical schools.
Two of the most influential medical schools in the Arab world are in Cairo and Khartoum. Consideration of the factors shaping medical training and research in these institutions should help shed light on the problems that affect the entire region.
The Rise of Modern Medical Education
Until the latter half of the 19th century, medicine in Europe and North America represented no standardized body of scientific knowledge. It was divided into different sects, such as homeopathy (treating disease with small doses of drugs or other remedies that in massive doses produce the disease itself) and allopathy (treating disease with remedies that produce different symptoms than the disease being treated). The science and art of medicine then was learned through apprenticeship.
The field of medicine began to take a sharper focus after the 1870s, with the discovery of the agents responsible for leprosy, anthrax, typhoid, tuberculosis, cholera, diphtheria, plague, malaria, pertussis and syphilis. Such impressive findings gave credence to a model where one could imagine that every illness had a specific microbe as its cause. The doctrine of “specific etiology,” as it was called, gained widespread acceptance in the era of positivist enlightenment. Researchers devoted themselves to isolating the causes (germs) of all diseases, and then to developing cures for them.
Advocates of the overly simple germ theory quickly overrode the work of the 19th century reformers who had highlighted complex social relationships, especially those between living conditions and health, as emphasis on the “micro” causes of disease came to exclude its “macro” causes. [2] The reformers had stressed that social and economic conditions have an important effect on health and disease, and that social as well as individual measures are needed to promote health and prevent disease. [3] The germ theory essentially depoliticized health by shifting the blame for disease to microbes, and facilitated a deeply conservative turn in understanding the antecedents of ill health.
In the early part of this century, colonialists brought this mechanistic, narrow view of disease to the parts of the non-industrialized world where they established institutions of higher learning. Thus, the political, economic and cultural dynamics of imperialism incorporated an already ideologically conservative conception of medicine, one concerned not with the social etiology of disease but with the germ theory. Elsewhere, private American philanthropies such as the Rockefeller and Carnegie Foundations poured resources into medical training and research institutions, further strengthening and spreading this narrow interpretation of medicine. [4]
The European powers had various motivations for bringing medical science to the colonies. Some physicians serving in the colonial health services believed that they were bringing the latest advances of medicine to uneducated (and unhealthy) local populations. [5] Others had a more calculating view of medical aid — including training and research — as a potent force for pacification. [6] They also saw its value in protecting their soldiers from endemic disease and in maintaining a healthy native labor force to meet European needs for workers. [7]
A Tale of Two Medical Schools
Egypt and Sudan provide illustrative case studies. Although intermittent epidemics of plague, cholera and typhus which once ravaged the populations of these countries now have been controlled, preventable infectious diseases still account for most deaths. Young children contribute the greatest numbers to the death registers; diarrhea, measles, respiratory infections and tetanus cause most deaths. In addition, the risk of dying during childbirth remains a serious threat to women. In Sudan today, malnutrition predisposes the population to disease and death.
One would expect these persisting problems to be the focus of medical research and care, and to receive prominent attention in the training of physicians. This is not the case in either Egypt or Sudan, and a tale of two medical schools, one in Cairo and one in Khartoum, will help explain why not.
Kasr al-Aini, Cairo University’s School of Medicine, dates back to the period of French influence in Egypt. [8] When Napoleon Bonaparte occupied Egypt in 1799, he made Kasr al-Aini a hospital for his troops. Soon after, a French commission proposed that a school be established where Egyptian students would be taught the medical skills required by Napoleon’s army. Muhammad Ali, the ruler, consented to open a medical school in 1827. The director of the school was a Frenchman, Antoine Clot “Bey,” and its professors were French, Spanish, Italian and Bavarian.
As Britain came to dominate Egypt in the latter half of the 19th century, there was a corresponding shift toward British involvement in the school. School histories suggest that under the British influence Kasr al-Aini became comparable to the modern schools of Europe. English became the sole language of instruction, the professors and textbooks were foreign, and the curriculum was revised to emphasize ever narrowing clinical specializations at the expense of public health.
In the early 1900s, Egyptian nationalists pressed for less foreign involvement in Kasr al-Aini. In 1908, Saad Zaghlul demanded the replacement of foreign teachers with Egyptians, but he never questioned the appropriateness of the subjects taught. Indeed, the Egyptian government increased the number of individuals sent on training missions to Europe. Egyptian education authorities were preoccupied with attaining scientific standards defined in Europe and measured by Europeans. That desire underlies Kasr al-Aini today, where training emphasizes treatment of “clinically interesting” cases of rare disease and deemphasizes prevention of the common ailments afflicting large numbers of Egyptians.
In Sudan the situation developed along parallel lines. The Kitchener School of Medicine was established in Khartoum in 1924, through public and private contributions, with the clearly stated objective of training Sudanese in medicine appropriate to Sudan. The early curriculum emphasized tropical infectious diseases. Dr. Squires, a British physician serving in the Sudan Medical Service, writes in his memoirs that “the new Sudanese doctors were to be trained as general purpose doctors and might have, particularly in out-stations, to cope singlehanded with whatever material [sic] came to the hospital for treatment.” [9]
Instead of concentrating on health problems prevalent in Sudan, though, medical training in Khartoum shifted toward the European standard. In the world of science, training and technology appropriate to developing countries are often viewed as second best, so long as the standards of “real” science are defined in the institutions of powerful countries. British examination assessors and visiting professors represented the major medical institutions in Britain — the Royal (Medical) Colleges and St. Thomas’, St. Bartholomew’s, Middlesex, University College and Kings College Hospitals.
In 1939 the external examiners judged the Kitchener course as falling short of European standards. They recommended changes to make the curriculum conform more closely to the British model. By 1946 the course consisted of a year-and-a-half of anatomy and physiology; half a year of pharmacology, bacteriology, parasitology and introductory medicine, and three more years of clinical medicine — an exact replica of courses in London. Moreover, as European medicine became more technologically oriented, more hospital-centered and more highly specialized, such standards were imported to Khartoum by the visiting experts. The budding Sudanese medical profession did not want to practice “inferior science.”
Specialization became the natural next step for Khartoum graduates. Such training was only available abroad, and admittance into institutions offering post-graduate training meant that the undergraduate curriculum of Khartoum had to meet specifications established abroad. The circle was complete. Khartoum graduates trained in Europe would return to Khartoum to impose the same inappropriate vision of medical science and European curriculum in their home institution. [10]
Innovations at Gezira
In 1975, a few courageous educators made a pathbreaking attempt to move beyond that cycle of inappropriate training. They established the University of the Gezira, situated in the heart of Sudan’s most densely populated central region, to train Sudanese in skills necessary for development. (Ironically, Gezira is where the British colonial regime constructed a dam and canal system to create the huge cotton cultivation project known as the Gezira Scheme. Ellen Gruenbaum found in the Gezira Board Archives evidence of the regime’s concern for malaria prevention to maintain labor productivity. “The thousands of Egyptians brought in to work on the construction had lower resistance to Sudanese malaria than the indigenous population,” she writes. “In response, they were ordinarily separated from the Sudanese workers in the hope that the same mosquitoes would not bite both groups…”) [11]
The new university, with faculties of agriculture, science and technology, economics and rural development, and medicine, stresses interdisciplinary training and practical problem-solving in its undergraduate curriculum. Dr. Bashir Hamad, a physician with a clear vision of the sort of doctor required in Sudan, set up the faculty of medicine in 1978. He recruited a talented and committed faculty to teach, conduct research and collaborate with local ministry of health institutions to provide care to the residents of Wad Medani and surrounding rural districts.
The five-year course, leading to an MBBS (bachelor of medicine) degree, aims at producing well-trained community-oriented doctors. [12] As such, Gezira departs significantly from traditional medical schools such as Kasr al-Aini or Khartoum, which have minimal contact with the community and a different sequence of courses. At Gezira, students study anatomy, physiology and biochemistry along with clinical sciences from the start, and meet patients and community populations early on. Gezira presents material in such a way that the students see immediately its relevance to their future practice. In traditional schools, subjects correspond to the departmental divisions, so students get a fragmented picture of the human body and its processes. At Gezira, courses address the critical problems which will confront a doctor in Sudan — growth and development, problems of the musculoskeletal system, nutrition and nutritional biochemistry, human environment, primary health care and family medicine.
Training at Gezira rests on three principles. First, it is community oriented. Training is not limited to the classroom, laboratory or specialty hospital. Students spend time with families, and in rural health centers and villages, where they are introduced to the promotion of health and the prevention and treatment of the most common health problems. They learn about the “macro” causes of ill health, and also about communicating clearly and respectfully. Because students work in regular Ministry of Health facilities rather than specially designed university teaching hospitals, they learn about administering health care under the real constraints operating in Sudan.
Second, the training is problem-based. At Gezira, staff believe that effective learning takes place through active rather than passive participation of students. Lectures are not common. Instead, through group discussions, self-instruction, individual and group assignments, seminars and project work, students are encouraged to solve problems. Teachers outline the problem and direct them toward the relevant technical facts. For example, Gezira students confront biochemistry through the investigation of malnutrition and its biochemical determinants, rather than through assignments to memorize biochemical formulae, as is often the case in traditional medical schools.
Third, the training is interdisciplinary. In their summer field program, medical students work on development projects with students from other fields and in the classroom groups of professors representing different medical specializations join seminars prepared by students. Each of these activities stresses cooperation, communication and team work, all necessary skills for the community-oriented doctor.
Effective Innovations?
Applying these laudable principles has not been easy. It is risky and difficult to budge a powerful profession away from its narrow focus, particularly when so many incentives reinforce the status quo. In fact, Gezira’s difficulties are less a reflection of Gezira’s own internal organization and more illustrative of two systemic problems: its divergence from the orientation of the conservative medical profession, and the inability of the health care system to incorporate a radically different kind of doctor.
The medical faculty’s first problem was to convince its own students of the validity of its approach. In Sudan as elsewhere, students are often attracted to medicine for the promise of professional power and prosperity associated with its clinical branches, not the less prestigious and lower-paid preventive and public health fields. At Gezira, training did not live up to the expectations of the first batch of medical students, who called a series of student strikes in the first year. The students feared that they would graduate as low-status paramedics, not as real physicians, and that they would not be trained to a standard where they could go on to post-graduate specialties. “To start with,” said founder Bashir Hamad, “the students were naturally apprehensive of this whole new approach and worried incessantly about their future. Khartoum University…provided a comparison with its classic and infallible approach.” [13] Staffs of competing medical schools also dismissed the Gezira experiment as unrealistic and unscientific — “They’re training health workers, not real doctors!” scoffed one Egyptian professor of community medicine — and this affected the students’ opinion of the Gezira faculty.
Over the years, however, the faculty has been able to evaluate the performance of its students and first graduates. They demonstrate competence in clinical fields equal to — in some cases superior to — those trained in traditional medical schools. They also are better able to integrate both preventive and curative aspects of medicine into their practice. But does the system in which they work after graduation allow them to be different from, and better than, more traditionally trained physicians?
For Gezira graduates to perform their functions as they have been trained, the health care system itself requires modification. Ideally, they should be part of a team — including nurses and other paramedical personnel — providing basic preventive and curative care. Unfortunately, most Ministry of Health employees perform only the most traditional of roles: treating disease. The overwhelming demand for curative care absorbs all their professional time. (This problem has been identified in Latin America as well, where universities in Mexico, Costa Rica and Nicaragua have attempted to produce doctors similar to the Gezira ideal. [14] Only in Nicaragua, where new physicians are employed in a well-institutionalized public health system which encourages community action and preventive medicine, do the graduates of innovative programs have the opportunity to work as they have been trained.) Gezira graduates thus have no clear professional niche in which to fit as doctors trained in a new kind of medicine. Moreover, they see Gezira professors operating private clinics in the evenings to supplement their meager academic incomes, offering them no new radically different role models.
Innovations in medical education in developing countries are extremely important insofar as they represent an indigenous challenge to Western definitions of “science.” They require enormous personal courage and professional commitment to progress and should be commended. In countries such as Egypt and Sudan, better medical education is only a small piece of the puzzle in improving health status. For a start, the official health care system must be organized so as to use the new graduates effectively. This does not happen automatically. It requires high level political commitment to public health, restricting income-generating private clinics and redirecting financial resources to promotive and preventive schemes in the community. These go directly against the strong vested interests of the medical profession.
In the end, positive transformations in health status will occur only when the living and working conditions of people improve. These are essentially outside the medical domain. By virtue of their status, doctors can be strong advocates for health in public forums, and therefore it is important that they understand the social, economic and political context of health and illness. Health will improve when standards of living improve, when incomes are more equitably distributed, and when public sanitation and housing conditions improve. Services will become better when ordinary people, knowing they have a right to respectful and truly useful health care, demand it of the system.
Endnotes
[1] World Health Organization, Regional Office for the Eastern Mediterranean, Health Manpower Development in Countries of the Eastern Mediterranean Region (Alexandria, 1986).
[2] Vicente Navarro, “Work, Ideology and Science: The Case of Medicine,&rdquo in Social Science and Medicine 14c(1980), pp. 191-205.
[3] See James Trostle, “Early Work in Anthropology and Epidemiology: From Social Medicine to the Germ Theory, 1840-1920,” in C. Janes, et al, eds., Anthropology and Epidemiology (Dordrecht: D. Reidel Publishing Co., 1986). For an excellent discussion of the theories of disease causation see: Stephen Kunitz, “Explanations and Ideologies of Mortality Patterns,” Population and Development Review 13,3 (1987), pp. 379-408.
[4] Howard Berliner, A System of Scientific Medicine (London: Tavistock Publications, 1985); and E. Richard Brown, “Exporting Medical Education: Professionalism, Modernization and Imperialism,” in Social Science and Medicine 13a(1979), pp. 585-595. See also Brown’s Rockefeller Medicine Men (Berkeley: University of California Press, 1979).
[5] H. Squires, The Sudan Medical Service: An Experiment in Social Medicine (London: Heinemann, 1958).
[6] L. Bousfield, Sudan Doctor (London: Christopher Johnson, 1954).
[7] See Ellen Gruenbaum, “Struggling with the Mosquito: Malaria Policy and Agricultural Development in Sudan,” in Medical Anthropology (1984); and Meredith Turshen, The Political Ecology of Disease in Tanzania (New Brunswick: Rutgers University Press, 1984).
[8] F. M. Sandwith, “The History of Kasr al-Aini and the Modern School of Medicine in Egypt,” British Medical Journal (September 20, 1902), pp. 909-910; and Naguib Bey Mahfouz, The History of Medical Education in Egypt (Cairo: Government Press, 1935).
[9] H. Squires, op cit.
[10] S. Akbar Zaidi, “Undergraduate Medical Education in Underdeveloped Countries: The Case of Pakistan,” Social Science and Medicine 25 (1987), pp. 911-919.
[11] Ellen Gruenbaum, op cit., quoting from the Sudan Gezira Board Archives.
[12] Bashir Hamad, “Medical Education at the University of Gezira, Sudan: A New Approach,” Proceedings of the Sixth Saudi Medical Conference, Jeddah, 1981. See also “The Faculty of Medicine University of Gezira: Another Step Towards Community-Oriented Teaching Process,” The Learner 9(1981), and “Problem-based Education in Gezira, Sudan,&rdquo in Medical Education 19(1985), pp. 357-363.
[13] The Learner, 1981.
[14] P. Braveman and F. Mora, “Training Physicians for Community-Oriented Primary Care in Latin America: Model Programs in Mexico, Nicaragua and Costa Rica,” American Journal of Public Health 77,4(1987), pp. 485-490.
