TOWARDS AN APPROPRIATE HEALTH CARE TECHNOLOGY

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Title: TOWARDS AN APPROPRIATE HEALTH CARE TECHNOLOGY
extracted text: SP^-~RF-Ar-3.l5

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SDA-RF-AT-3.15

Christian Medical Commission World Council of Churches

150 Route de Ferney 1211 Geneva 20 Switzerland

SDA-RF-AT-3.15

April 1972

TOWARDS AN APPROPRIATE HEALTH CARE TECHNOLOGY
Oscar Gish*

It has taken many years for today's industrialized countries to ad
vance to their present state. Not surprisingly, the countries of
Africa, Asia and Latin America also aspire to create technologically
advanced societies. Clearly, this task ought more easily to be ac
complished now than in any earlier period, the major reason being
the existence of the sophisticated technologies which are flowing
from the advances in science to be seen in Europe and North America.
It would seem to be a relatively simple matter for countries in the
Third World to utilize already existing techniques, many of them
highly productive, for purposes of development.
Unfortunately, the mere existence of advanced techniques does not
assure the possibility of their application to the problems of de
veloping countries. The technologies which are being developed
and utilized in the advanced countries are, as would be expected,
suitable for the resource base of those countries. Many of them
require a relatively abundant supply of capital, and a scarcity of
labour is generally assumed. By contrast, virtually all develop
ing countries are suffering from severe shortages of capital and
a vast oversupply of available labour, particularly of the unskilled
variety. What is required in countries of the latter kind is a tech
nology designed to take advantage of their large supplies of labour
and to minimize the need to draw upon their scarce pool of available
capital.
Bust as the new technologies of Europe or North America are likely
to have only limited applicability to the problems of the Sudan or
Malaysia, so too with many of the exciting new discoveries in the
various areas of pure scientific research now being carried out in

♦Oscar Gish has studied in the United States, the Netherlands and
Great Britain, where he has achieved degrees in history, the social
sciences and economics. He has acted as consultant to a number of
governments and international organizations.

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the industrialized countries. Because 98 per cent of all research
and development activity is being carried out in the developed coun
tries and only two per cent in the developing countries (excluding
the Socialist countries from the calculation), the developed coun
tries must inevitably determine the 'frontiers of science' on which
scientific workers will prefer to be engaged. And, just as inevi
tably, the frontier problems which will be of interest to scientific
workers in developed countries will be those that stem from the socio
economic conditions of those countries. As such, they will be of only
limited usefulness in those parts of the world with very different
socio-economic conditions.
All of this is not to argue that new scientific and technological ad
vances have no relevance to the situation of developing countries, at
least in the long run; however, it is fair to say that their useful
ness - particularly in the short run - is likely to be limited. One
important proviso to the above is the possibility of creating new
technologies (or reviving old ones) which are specifically geared
to the resources and capabilities of the less developed countries.
Most important in this respect is the need to adapt existing knowl
edge in the interests of development.
One important technological area in which sufficient knowledge either
already exists or need only be adapted for specific conditions is
that of medical care. The conditions of morbidity and mortality in
developing countries are such that no new medical discoveries are
necessary in order to reduce the incidence of disease and death to
orders of magnitude which may be only a quarter (eg., infant morta
lity) or even a tenth (eg., childhood mortality) of their present
levels.

There exists increasing agreement among those connected with the
'creation1 and 'delivery' of health care that future improvements
in these areas will be achieved primarily through innovations in
health delivery systems in both developed and developing countries.
Although many of these necessary innovations could only be accom
plished in conjunction with very far-reaching social, economic and
political change, very many others could be accomplished even in
the absence of sweeping reforms. There would be need for changes
and adjustments, in any event, but none need be totally unaccept
able to existing political, social, economic, professional or bu
reaucratic interests. Any proposals designed to reorientate as com
plex a system as that employed for the delivery of health care must
inevitably meet with numerous resistances, but there is no reason to
assume that these obstacles cannot be overcome.
The concept of an appropriate technology for health care recognizes
that all countries are subject to limitations in their ability to
provide care. No country in the world makes available, or can make
available, all of the existing, most advanced medical techniques to
all of its citizens. Even in those countries in which access to
care is most equitable, such as the Soviet Union and the United King
dom, there are still differences in the treatment available to, say,
those who live in London or in Moscow and those in the far reaches

3

of Scotland or Siberia. The answers to the problems of developing
improved health care systems are not to be found, either, simply
in the expenditure of larger and larger sums for health purposes.
The example of the United States, with its vast expenditure on
health care and relatively poor morbidity and mortality statistics,
is evidence of this.
The realization that unlimited health care cannot be achieved even
in highly industrialized countries has given support to the concept
of an appropriate, intermediate health care technology. This con
cept is even more suitable in countries which may be spending as
little as a hundredth part of the amount being spent in Britain for
the health care of each inhabitant.
Appropriate technologies are intermediate in nature; that is, they
will fall somewhere in the midst of those which use most capital,
those which use most skilled manpower, those which are most diffi
cult to maintain, and those which are completely traditional in char
acter. This very wide range of possibilities must be narrowed down
in keeping with the requirements of individual countries at specific
times. Clearly, what is a suitable intermediate technology for
Britain will not be so for Nigeria.

Intermediate health care technologies in developing countries will
take advantage of the supply of labour available and conserve capi
tal. One particularly important by-product of such an approach will
be to help decrease the catastrophic political, social and economic
effects which vary high levels of unemployment are having on develop
ing countries.
HEALTH PLANNING IN DEVELOPING COUNTRIES
There are three basic reasons why planning for health care must be
radically different in rich and in poor countries.

money as well as
Eirst there are the different levels of resources
available
to
rich
and
to
poor
countries.
skilled manpower
In 1969 the United Kingdom spent about £40 per head of population to
keep its National Health Service operating. The United States spent
almost £125 per head for health services in that same year. By con
trast, Ethiopia spend around 20p for the health care of each of its
22 million people. The expenditure for health in Britain represented
about five per cent of the country's Gross National Product. Ethio
pia's expenditure represented perhaps 0.6 per cent of its GNP. Even
if the Ethiopian expenditure for health care were to be multiplied to
a figure equivalent to Britain's, the total outlay would then only be
around £1.25 per head.

Differences in the availability of financial resources are also re
flected in the statistics for hospital beds in rich and poor coun
tries. While there are 10 beds for every 1000 of the population in
the United Kingdom, there are fewer than two per 1000 in Mexico and
only 0.4 per 1000 in India.

4

The disparity in the number of available medical workers is no less
great. In the United Kingdom there is one doctor for every 860 peo
ple, but there is one for each 5000 in India, one for each 13,000 in
Haiti, and only one for every 30,000 in Nigeria. Also to be taken
into account is the fact that doctors are much more evenly spread,
relative to population, in a country like Britain than they are in
such countries as India, Haiti or Nigeria.

A second basic reason for the need for different types of health
planning in rich and poor countries is the differing structure and
location of their populations. In a developing country a third of
the population will be under 10 years of age - two or even three
times the percentage to be found in most industrialized countries.
Another basic factor will be their rates of increase. In most
wealthier countries population is increasing at between 0.5 per
cent and two per cent per annum. In developing countries the in
crease is more likely to be nearer 2.5 per cent or even three per
cen t.
Distribution of population is also very different in developed and
developing countries. Rural areas are likely to hold 50 per cent
to 90 per cent of the population of developing countries, but in
the United Kingdom only 5 per cent and in the United States only
10 per cent of the population is classified as rural,
In addition,
the rapid rate of urbanization in poor countries presents special
problems. UJith urban areas increasing at around 6 to 8 per cent a
year, the growth of shanty towns is of particular importance.

The third basic reason for approaching health planning differently
in rich and poor countries is the drastic difference between exist
ing disease patterns in the two types of nation. In the developing
countries there are so many children, and their disease patterns are
so inadequately cared for, that half or more of all deaths occur
among children under five. In the United States, by contrast, over
half of all deaths are caused by diseases of the heart and blood
vessels, primarily among people between 50 and 70 years old.
In developing countries infant mortality (0 to 1 year) may be four
or more times as high as in industrialized countries, whereas child
hood mortality (1 to 4 years) may be more than 40 times as high.
Children in poor countries typically die from diarrhoea, pneumonia
and malnutrition. The diseases of the developing countries are
largely those of poverty.
Resources: Facilities
How then should a country with perhaps 50p a head to spend on the
health care of its population ( a not untypical figure) ultilize its
limited financial resources?

In rich countries the focus of health care has been shifting gradual
ly away from the family doctor/general practitioner to the hospital
and hospital-based specialist. This process has not been an easy one
and its desirability has been called into question. Desirable or not,

5

it must be recognized that the massive shift to hospital-based medi
cal care is of fairly recent origin and coincides with other aspects
of change associated with economic development.

In most low-income countries the same sort of hospital-based medical
care systems are being established, or at least attempts are being
made to establish them. However, in the absence of substantial eco
nomic development, such hospital-based systems are making impossible
the spread of essential health services to the mass of the popula
tion. It is not unusual for the capital costs of a large city or
regional teaching hospital in Africa to be greater than the entire
annual health budget of the country. The cost per bed in such cir
cumstances may very well run upwards of £5000, and that in countries
with incomes as low as £30 per head of population.
In principle, teaching hospitals in the capital city function not
only as the teaching base for the medical school (as well as being
a centre of research) but also as the peak of a medical care refer
ral system. That is, patients from all parts of the country are
sent upwards along a health care chain which starts with aid sta
tions or dispensaries or health centres, then moves up through rural
and district hospitals, and finally ends with the capital city teach
ing hospital. Hospital-based medical care and the hospital referral
system are, however, likely to work only to a very limited extent.
For instance, in Ghana it is estimated that fully two-thirds of the
population are not effectively covered by government curative health
services, which are primarily available only at hospitals. The in
adequacy of the hospital-based referral system may be illustrated by
data drawn from the Mulago Hospital in the Uganda capital of Kampala . 1
In 1964, of all admissions to Mulago, 93 per cent came from the Mengo
District in which Kampala is located; even if we exclude obstetrics
and gynaecological admissions, 98 per cent of which were from Mengo,
the figure only comes down to 88 per cent. Clearly then, Mulago
Hospital - at least in its curative work - is primarily serving as
a district hospital. The same is true of most others of its kind.
They are not truly national health centres.
Rural and district hospitals need not be as expensive as teaching
hospitals. A bed in a teaching hospital in Africa will cost about
£5000, and a bed in a district hospital perhaps £2000. A rural hos
pital bed will generally cost half to three-quarters of that figure,
and sometimes even less than half.
The cost of equipping and running hospitals are related to their cap
ital costs. But the larger, more expensive hospital will not only
have a higher running cost owing to its size, the cost will also be
proportionately higher than for the small institution. One major
reason for this is that a teaching hospital will have more special
ists on its staff, more general duty doctors, more registered nurses,
and so on, than a district hospital, and a district hospital in turn

Ip.O.S. Hamilton and A. Anderson: An Analysis of Basic Data on Admis
sions in 1963 and 1964 to Mulago Hospital, Kampala.

6

mill have more than a rural hospital. The more capital-intensive
a hospital is, the more skill-intensive it is likely to be.
Poor countries (if not rich ones as well) concerned with reaching
the whole of their population with a health service must find an
alternative to a system which depends upon hospital beds costing
from £1000 to £5000 'or more' each. That alternative is a health
delivery system which reaches the population at the lowest possible
level. The accepted way of reaching a large rural population is
through the health centre with its outlying aid stations or dispen
saries. The health centre aims to provide the entire health re
quirements of a family except those which can only be provided in
a hospital. A health centre in Africa can be built for somewhere
around £20,000 - the cost of four beds in a teaching hospital - and
can provide most of the health care requirements for roughly 20,000
people. In a country such as Zambia, 250 health centres, enough
for the entire population, could be built at the cost of the new
teaching hospital in Lusaka.2 The recurrent costs of such a health
centre are not likely to be more than £10,000 a year, or 50p for
each of the 20,000 people covered by the centre. Thus a country
with only 50p per capita to spend for health care could still pro
vide basic health care services for its entire population.

Properly staffed, a health centre can supply at little cost much of
the medical care required by the people of a developing country.
This is because so many of the diseases from which these people
suffer are what might well be termed 'health centre diseases': con
ditions which health centres are particularly well able to prevent
or treat. Typical functions might include the prevention through
immunization of measles (one of the most important killing diseases
in many developing countries), tuberculosis, poliomyelitis, small
pox and whooping cough, and, through the health education of mothers,
the prevention of the widely prevalent malnutrition in childhood.
IY1 ost cases of many common diseases can also be readily treated in
these centres; among them are leprosy, tuberculosis, pneumonia,
gonorrhoea, diarrhoea and dehydration (especially in childhood),
malaria and hookworm infection. Health centres can provide family
planning services, antenatal care, care of the normal delivery,
child welfare facilities, school clinics, advice on environmental
sanitation, and curative clinics for a wide range of important dis
eases. Health centres do not have operating theatres, X-ray plants,
or more than minimal laboratory services, nor can they provide a
doctor's opinion, so one case in 100 has to be referred to a dis
trict hospital; common among such cases are the abnormalities of
labour and the consequences of trauma, particularly from accidents
on the road. A district hospital in its turn has to refer about
one per cent of its cases to a regional or national hospital for
specialist opinion or special facilities.

This account of health centre services is, of course, oversimpli
fied in that it assumes an evenly (and conveniently) spread popu2|YI.H. King: A Teaching Hospital for a Developing Country.

1

lation so that each health centre can cover its required number of
people. Many countries, however, have very low population densi
ties with people either scattered in small villages or perhaps even
nomadic. Such situations are usually best met with systems of aid
stations and mobile clinics run from health centres.
Assuming that the generalized health centre service does cover a
country fairly well, it is still necessary to provide certain spe
cialized hospital services in addition; these necessary services
do not include radiotherapy, neurosurgery, cardiac surgery, arti
ficial kidneys and organ transplantation.
The kind of hospital services required in poor countries must be
provided in what are usually known as district hospitals, even if
such hospitals have to be built in large cities where a number of
them can be located in order to provide sufficient scope for teach
ing and many research purposes. A crude 'guestimate' would indi
cate that for 50p per head it would be possible to run a network
of such hospitals so as to cover an entire population. However,
this would mean spending £1 per person (50p for health centres plus
50p for hospital services) for health care instead of the 50p now
being spent generally in Africa or Asia. The choice would then be
either to reduce health centre or hospital coverage, or to raise
expenditure on the health services. For a country with a per capita
income of, say, £40 to spend £1 per head or 2.5 per cent of the
nation's GIMP would not be unreasonable for health expenditure.
(Developed countries spend twice that figure, and underdeveloped
countries are spending considerably more on, for example, education.)

Resources: Manpower
The kind of facilities employed for delivering health care are crit
ical in determining the type of manpower employed. Large capital
city hospitals, of the type discussed earlier, require specialist
and other highly qualified manpower if they are to do their proper
jobs, namely, specialized medical research, teaching of highly qual
ified manpower, and the care of patients suffering from the 0.1 per
cent of health problems which cannot be handled adequately in smaller,
simpler institutions. In many developing countries there is not suf
ficient staff to man the existing large hospital facilities. Ethiopia,
for example, has built a large new hospital for teaching purposes with
out any immediate prospects of staffing it.
In this connection it is
worth noting that in 'Africa the number of doctors per head of popula
tion actually declined between 1962 and 1965, as a study of two groups
of 13 francophone and 13 anglophone countries has shown.3 in 1965,
among these countries, there were three with one native born doctor
for less than 20,000 inhabitants, nine with one to 20,000 to 50,000,
eleven with one to 100,000 and more, and two countries with not one
indigenous doctor at all.

^0. Vysohlid (1960): Health Manpower in the African Region. Economic
Commission for Africa Working Party on Manpower and Training, Addis
Ababa. UN Economic and Social Council (mimeo E/CN 14/lUP 6/19).

B

These figures, however, do not show the real situation because of
the concentration of medical personnel in the capital cities.
In
eleven African francophone countries in 1965, about 60 per cent of
the indigenous and 50 per cent of the expatriate doctors were lo
cated in the capital cities.
Health centres, in contrast to hospitals, can be operated by a variety of men and women with middle level skills, even in the virtual absence of anyone with a university education,
The variety
and scope of auxiliaries, as well as paramedical staff, has been
outlined elsewhere.4 Here it will suffice to say that, in general,
the various types of auxiliaries make up a skill continuum which
extends from those with very little education and training (say,
six years of schooling and virtually no training) to those with
complete secondary education plus a number of years of training.

Paramedical staff should not be confused with auxiliaries; they in
clude registered nurses, pharmacists, laboratory technicians, health
inspectors and other staff who are fully qualified professionals.
They usually do not, however, have the university education re
quired of doctors, although their international status is usually
recognized.
The medical assistant is the key auxiliary. He is the major pro
vider of primary medical care in many African and Asian countries.
For example, in Kordofan Province in the Sudan there were 2.1 mil
lion inhabitants in 1969. This population was served by 36 doctors
located in 12 hospitals; there were also 81 medical assistants in
81 dispensaries, and 126 qualified nurses in 126 dressing stations.
It is these medical assistants and qualified nurses who were pro
viding the bulk of the health care for the people of Kordofan Prov
ince .
At present the Sudanese medical school in Khartoum is producing 30
graduates per year. It is proposed to raise that number to 160 by
1975. Is it then reasonable to expect that, given time, doctors
will gradually replace medical assistants in the Sudan?
The education received by medical students in the Sudan is virtually
indistinguishable from that of medical students in, say, Britain;
that is, medical education which is very much in tune with hospital
based practice and entirely consonant with employment in a large city.
At present over a third of all Sudanese doctors work in the capital
city, where about five per cent of the population live. In future
the increased output from the medical schools is likely to find it
self concentrated in the capital city to an even greater extent than

is the case at present. This phenomenon can be seen clearly in other
countries in the Middle East and Asia (eg., India, Pakistan, Iran)
which have been increasing rapidly their output from medical schools
but can still show no very significant increase of doctors outside
the capital cities and other large towns.
^See, for example, M.H. King (1966): Medical Care in Developing Coun
tries, Chapter 7.

9

In time, as the larger cities become saturated with medical men,
some will have to move to the smaller centres.
But perhaps an
even greater number will escape the burden of excessive competi
tion in the cities by emigrating to another country altogether.
In the United States there are already 25,000 medical graduates
from schools in developing countries, and in Great Britain there
are close to 10,000 doctors who were born in Asia and Africa primarily in the Indian subcontinent.
Canada, Australia, Germany
and France have also become the beneficiaries of medical person
nel born (and usually trained) in the Third World. 5
The medical 'brain drain' from the developing countries is an ex
tension of the general problem of providing medical education and
health manpower planning which is suitable for the conditions of
poor countries.
If doctors are trained in postgraduate special
ties, of which poor countries can support relatively few practi
The
tioners, it is inevitable that numbers of them will emigrate.
crux of the problem is whether to train doctors for the needs of
the mass of the population who are rural dwellers with low effec
tive economic demand, or for those relatively few urban dwellers
who have a high effective economic demand.
If the increasing num
bers of medical graduates in developing countries are all to enter
into urban competition with each other, some of them must neces
sarily emigrate; they cannot all practise successfully among the
relatively small urban middle and upper classes.
It is clear that careful attention must be paid to the likely ef
fects of a particular kind of medical education and further spe
cialization.
If international emigration of doctors is 'only' an
extension of the rural-urban migration problem, the type of medi
cal education that will forestall international emigration is also
likely to increase the number of doctors working in the countryside.
Medical education has to be geared to the type of health problem ex
perienced by a given country's entire population.
If 90 per cent
of the population is rural, then 80 per cent of the medical students
should be educated accordingly.
Because the causes and prevention
of illness, disease, and death vary in rural and urban areas, the
80 per cent or so of doctors who should be preparing for work in ru
ral areas must come to know the causes that are connected with rural
life, and the consequent methods of prevention of illness, disease,
Successful medical education, intended to
and death in those areas.
produce doctors for rural areas, should be orientated towards work
in those areas, and new curricula must be designed for such purposes.
Two corollaries which follow from the above discussion are: first,
the desirability of producing a doctor with the minimum and there
fore the least expensive training necessary to fulfill his duties;
^The discussion about medical 'brain drain' which follows is drawn
from Oscar Gish: Medical Education and the Brain Drain, British
Journal of Medical Education, Vol. 3, No. 1, pp. 11-14.

10

and second, the need for at least part of that man's medical train
ing to be carried out in a district or rural hospital in the country
side.
The solution to the problem of how to retain doctors in their own
countries, and in rural areas, is to be found in their training.
Those who are chosen to study medicine must be committed to the
health requirements of the mass of their country's population.
Their education must then reflect their commitment. It is too
late after medical education has been completed substantially to
change the pattern of a doctor's life. That pattern has already
been set by the nature of the training he has received. If medi
cal training has prepared a doctor only for medicine as practised
in a modern teaching hospital, he must then either practise in his
country's capital city or go abroad.
Tax and housing incentives might be among the means for drawing doc
tors to the countryside. Still more desirable are active health
centres and good and interesting professional conditions in the ru
ral areas. Travel, promotion and honours should go to rural medi
cal workers in recognition of their important work. Needless to
say, the national health budget should be allocated fundamentally
in keeping with the nation's population distribution.

It is, hotuever, suitable medical education that can lay the founda
tion for keeping doctors usefully employed in their home countries.
Part of the process of suitable medical education is a selection
process. The likelihood of a given medical student remaining at
home upon completion of his studies is one key element in a prop
erly organized medical selection process.
In a developing country one of the doctor's main roles is to act as
teacher, supervisor and consultant to a team of auxiliaries. He is
most often required to fill this role by supervising a series of
health centres in the rural areas or by running a district hospital,
and this not only for a year or two after qualification, but for the
majority of his professional life. There is an increasing realiza
tion that the best way of achieving this state of affairs is not to
train him in a lavish, thousand-bedded, chromium-plated, multimillion
pound teaching hospital which accustoms him to facilities that cannot
be reproduced elsewhere in the country, and which therefore dissuades
him from working subsequently in a district hospital. Rather, it is
to train doctors under conditions which are much closer to those in
which they will later have to work, particularly in district and ru
ral hospitals. This is indeed the policy of the new medical school
in Zaria, Northern Nigeria, which is breaking away from the traditions
set by earlier medical schools in Africa with their inappropriate if
otherwise excellent patterns of training.
What is required then is a sufficiency of suitably trained doctors
equipped to lead teams of medical auxiliaries. These teams should
be part of a health centre service (under a director of health centre
services) which acts as the basic carrier of health services in the
country. Such a health centre service should be the base upon which

11

all other health care in the country rests. The focus of medical
attention must be shifted from the big teaching hospital on the cap
ital city hilltop to the unobstrusive health centre in the village.

Population; Structure, Location and Growth
The populations of developing countries are young, fast-growing
and still primarily rural in spite of rapidly increasing urbani
zation. All of these demographic imperatives give rise to special
health care considerations.
The diseases of children in developing countries are particularly
amenable to prevention in contrast to cure. The major killing dis
eases in poor countries are the group of childhood diarrhoeas,
pneumonia and protein calorie malnutrition (PCM). Following be
hind this 'big three' are tuberculosis, intestinal helminth infec
tions (worms), measles, whooping cough, malaria and accidents.
The nature of these diseases, coupled with the age structure and
rural domicile of the population, supports the view that the health
centre and the medical assistant are the basic instruments upon
which the health services must rest. Not only can health centres
fit more closely into the rural health as well as the general rural
environment, they can also offer an appropriate base for family plan
ning work within the context of maternal and child care activities.

Maternal and child health care can be best, if not only, carried out
close to or within the home environment of the woman and her child
- that is, mainly within the village. An exhibition of slides show
ing the dangerous diseases borne by mosquitos or snails, which is
seen in a two-room mud dwelling belonging to 'one of us', takes on
a significance which cannot be achieved in the context of a large
impersonal hospital building which belongs inevitably to 'them'.
The special problems connected with rapid urbanization must also be
kept in mind. The crowding together of large numbers of people in
to small, insanitary areas has placed intolerable strain on health
and social services in the towns and cities of developing countries.
Probably no other measures could do more to improve the situation
in these urban slums than the provision of fresh water in adequate
quantities and the installation of proper sewage disposal systems
together with a general improvement in sanitary and hygienic condi
tions. Beyond these, there are all the social services necessary
to deal with conditions which are making for increasing venereal dis
ease, mental illness and other social illnesses in the growing slum
areas which threaten to engulf many towns and cities in Africa, Asia
and Latin America and more than a few in Europe and North America as
well.

Disease Patterns and the Road Ahead
It has already been indicated that the types of diseases to be found
in tropical countries are in the first instance to be treated as aspects of poverty rather than of the tropics. This point can be nicely

12

illustrated by data drawn from the medical history of New York
City.6
Digestive System.
120

100
Respiratory System.
80
Infectious Diseases.
Tuberculosis

60

Premature Birtti'
Injury at Birth
Atelectasis, etc.

40

Congenital
Malformations
All other causes-

20

1900

1905

1910

1915

1920

1925

'30

Infant mortality by prominent causes in New York City (rates per 1000 births)

Throughout the 19th century the death rate in New York remained
constant at about 30 per 1000. A substantial part of that death
rate was due to a level of infant mortality which was not unlike
that which is to be found in developing countries today. As
shown in the graph, the first three decades of this century saw
a dramatic decline in infant mortality in New York City from 140
per 1000 to less than 60 per 1000. Of that fall, two thirds oc
curred in the diarrhoea-pneumonia complex of childhood diseases.
This striking decrease was accomplished by a series of measures
taken early this century. Some of the specific public health de
velopments of the period included an improved water supply, better
control over and distribution of foodstuffs, and the inauguration
of visiting nurse services and well baby clinics. This period also
saw the growth of paediatrics and, perhaps particularly important,
major campaigns against illiteracy and a substantial increase in
primary schooling.

It is not possible to argue that a specific set of measures taken
in the particular circumstances of New York City at the turn of the
century are necessarily relevant to all, or indeed any, of the coun
tries in Africa, Asia or Latin America today. What is clear is that
the road leading to the reduction of morbidity and mortality is not
necessarily paved with advances in medical science. In fact, the
6 The

discussion which follows is based on material presented by
W. McDermott in Manpower for the World's Health, a report of the
Institute of International Health Education (1966), ed. H. van
Zile Hyde.

13

technological possibilities inherent in already existing knowledge
about the causes, prevention and cure of disease are far greater
than our social and political (not to mention economic) ability to
utilize those possibilities fully.
The same road is more likely to be paved with social and political
advances, reflected in an improved system for the distribution of
health services, rather than with further scientific advances as
This last is probably not only true for poor but for rich
such.
countries as well.

INTER1Y1EDIATE TECHNOLOGY IN MEDICINE
Kenneth R. Hill*
In Northern Nigeria there is one doctor to 150,000 people, and the
problem of how to deliver medical care both in quantity and in qual
ity to such a populace requires urgent solution,
The conditions
found in Northern Nigeria are similar to those in many of the de
veloping countries.
In 1965 the World Health Organization laid down a minimum target
for the next decade of one doctor for each 10,000 of the population.
Throughout Africa (excluding Egypt and South Africa) the average
doctor/patient ratio was then 1:20,000.
To meet the WHO target,
an increase in the number of doctors in Africa from 10,000 to 24,000
was needed immediately.
This was roughly equivalent to the complete
Northern
10-year output from all the medical schools in Britain.
Nigeria alone would have required 17 times as many doctors to look
after its 30 million people as it then had, 3000 instead of 1751
In 1965 no local medical school existed, and the first 30 doctors
At
from the new medical school in Zaria will qualify only in 1973.
this rate it would need 100 years to provide 3000 locally trained
doctors to look after the people of Northern Nigeria, and the popu
lation there is expected to double by the year 2000...
Recruits for physician training must already have received a high
level of secondary school education.
Most developing countries are
handicapped by gross deficiencies in the primary and secondary school
In East Africa out of 1000 children attending pri
infrastructure.
mary school, only 10 go to secondary school and only one continues
training after leaving secondary school.
Educational priorities in
developing countries may have to be slanted towards increasing the
supply of primary and secondary schools rather than establishing
more centres for higher education in the form of universities.
But
physicians can only be trained at university level.
The medical
school has to compete with other equally important disciplines such
as agriculture, engineering and education among students eligible
for university places.
♦Professor of Pathology,
University of London

Royal Free Hospital School of Medicine,

14

To this handicap is added the phenomenal cost of producing a doc
tor.
It is estimated that the cost of training a physician is
In his recent book
£15,000 in the UK and £22,000 in the USA.
Health and the Developing World, 0.H. Bryant estimates that in
medical schools in the developing world it costs at the moment
up to 65 per cent more to train a student than the £22,000 this
costs in the USA.
The new African medical schools, such as
Lusaka, Zaria and Addis Ababa, hope to bring their cost per
student down to below even the British level, but they all have
yet to graduate their first new physicians.
In any event, teach
ing hospitals are very expensive, and Mr Gish shows elsewhere in
this publication how maintaining a university teaching hospital
can 'milk' the slender resources available for health care in a
developing country to the detriment of other services, especially
rural health.
Even if the countries concerned could afford the high cost of
training large numbers of physicians, too little thought has so
far been given to what type of doctor should be trained.
In the
West the modern medical school curriculum demands a high level of
education in the basic sciences, is highly specialized, and uses
sophisticated equipment and techniques; it is almost entirely
hospital-orientated .
There is little emphasis on community and
preventive medicine, on public health and health education.
This
type of training does not prepare the student for the pastoral
and general duties required in developing countries.
The majori
ty of the sick do not need the complex hospital facilities which
are part of modern medical thinking and education; but the doctor
has not been trained in selection and he tends to want to prac
tise in the shadow of the hospitals which are in urban areas.
The
diseases of the masses, which are in the rural areas where per
haps 75 per cent of the people live, are ignored, whereas the out
patient and inpatient departments of the district general hospitals
in the towns are swollen to gigantic size, cramming the hospitals
with people in numbered anonymity.
In India today, for example,
roughly 80 per cent of the population lives in the rural areas,
whereas approximately 80 per cent of the doctors are to be found
in the towns and cities.
The test of any educational programme lies in what the person ac
tually is able to do, not what he has been taught.
Dr Rosa, after
considerable experience in Ethiopia, has suggested some guidelines
for the training of a doctor who is to work in a developing country. 7
He writes that where there is only one doctor for as many as 150,000
patients, Western methods of training, even if intended for general
practice, are inapplicable.
The doctor cannot himself cope with each
individual case but must be trained as a leader in health programmes.
This training should be designed within the context of local prob
lems and should include the following:
7F. Rosa (1964): A Doctor for Newly Developing Countries - Principles
for Adapting Medical Education and Services to Meet Problems, Journal
of Medical Education, vol. 39, No. 10, pp. 918-924.

15

1.

Orientation towards the practice of preventive medicine and
public health at community level. This means the develop
ment of health services within limits which the people can
support locally.

2.

Training in the instruction and leadership of auxiliary work
ers. These may be people such as nurses, laboratory techni
cians and sanitarians who are literate and will already have
received some kind of formal training. Alternatively, the
auxiliary worker may be indigenous and illiterate. The lat
ter, however, given a brief training and modern tools, can
often achieve a greater reduction in sickness than the best
doctor managed to achieve 25 years ago.

3.

Instruction in handling mass campaigns against, for example,
smallpox, tuberculosis, syphillis, trachoma and malaria, to
gether with a widespread health education programme.

4.

The development of community self-help programmes, eg, better
water supplies, improved drainage.

5.

Knowledge of maternity and child health needs. In any devel
oping country a large proportion of the population will be
children, and improvement in nutritional standards, widespread
immunization against communicable diseases and instruction in
methods of family planning are vital.

6.

A sympathetic appreciation of local culture and resources.
Effective medication should be, as far as possible, cheap,
simple, practicable and suitable for use in field or clinic
rather than in a hospital.

Dr Rosa's proposals make use of intermediate technology in the form
of intermediary medical personnel such as nurses, medical auxiliaries,
sanitary workers who work as a team led by the physician. Dr Rosa's
practical suggestions make good use of the delivery of medicine to
large numbers of people and also emphasize the prevention of disease,
a subject which receives too little attention. Nigeria spends six
times as much on curative medicine as it does on preventive; yet it
has been estimated that even a doubling of the expenditure on pre
ventive medicine would transform the whole medical picture there.
Dr Rosa suggests using intermediary personnel in the delivery of
health care, and to some degree his suggestions are already being
accepted in the UJest. The identity and status of intermediary per
sonnel must therefore be clarified so that they can be accepted as an
essential part of the world health scene. It cannot but be admitted
that objections are raised by the established corpus of doctors to
the use of auxiliaries in medicine. The medical profession jealous
ly guards its right to diagnose and to prescribe, yet in actual prac
tice doctors are often forced to delegate this responsibility.

In the past, an auxiliary (or in this particular case a second tier
doctor) was extensively used in India, where he was called the

16

licensed medical practitioner or surgeon's assistant; in other terri
tories another intermediary grade was known as the medical assistant.
These systems worked well, for in practice it was found that the en
vironment conditioned the job rather than any particular scheme for
medical education or any government's particular health policy.

As many newly emerging countries achieved independence, this ujelltried form of medical practice was often discarded; but now even
the more sophisticated countries are being forced to adopt a policy
of delegation of responsibilities. This can be seen in both the
USA and the UK. In the USA, owing to the lure of specialization
in medicine, there is a dearth of general practitioners, of doctors
of primary contact, and intermediary medical personnel being trained
include the physician's assistant at Duke University in North Carol
ina, the nurse practitioner at Denver in Colorado, and the medexes
in Seattle, Washington, and various other places. Altogether 28 such
training schemes have received support from universities, state medi
cal associations and government, and these practice assistants give
primary medical care to thousands of people. In Britain, for similar
reasons, general practitioners are in short supply, and health cen
tres are being developed in association with the delegation of respon
sibilities to a host of intermediary personnel such as midwives, dis
trict nurses, health visitors and social workers. In the USSR.the
feldsher has been established for many years, especially in rural
areas. The feldsher resembles a nurse but with extra training in
diagnosis and treatment, and there are almost 400,000 (most of them
women) in practice in the Union. Intermediate medical personnel
like those already described, differing perhaps in skills but still
part of the national medical team, have been used for years past in
Sweden, in Spain (the practicante), and in France, where the druggist
in a French pharmacy dispenses a considerable amount of advice and
treatment and could well be compared with the English apothecary of
an earlier age, who became the general practitioner. In New Zealand
there is a newly established training school where medical reception
ists receive a year's training to enable them to act as 'doctor as
sistants'. The first intake of students have recently completed the
course and are being well received by the public.
Although the use of intermediary personnel is on the increase, resis
tance to their recognition continues, and this is often even stronger
in the developing countries than it is elsewhere. It is hard to
understand the rationale of such opposition. It is true there is
a remote danger of people with less advanced training developing in
flated ideas of their own capabilities, but such people can only be
relatively few and they will be found at the fringe.
It must be obvious throughout the world, and particularly in develop
ing countries, that we have not the resources or the educational infra
structure to produce the needed number of doctors through university
training. measured against the national incomes of developing coun
tries, the financial burden of educating masses of physicians cannot
be tolerated. It seems only logical that this vacuum, which has been
created by the present methods of training and practice, must be filled
by a well-trained and disciplined corps of intermediary personnel.

i .

17
These team members must have status, and the responsibility which goes
with that status, if well-balanced health teams are to be established.
The doctor can no longer be an individualist and an authority in his
own right. Instead increasingly, and particularly in hospital work,
he is becoming the leader of a team in which auxiliary personnel have
their rightful place. Such an attitude must now extend from the hos
pitals to the rural areas and to national health services throughout
the world.
4

If doctors wish to preserve their own status, they have to remember
their true role of service within and to the community by the applica
tion of scientific thought for the relief of man’s estate. Medicine is
to do with people. Although the practice of medicine today is so ad
vanced that academic training is essential to a physician, rather than
the old type of apprenticeship, the doctor of the future must not lose
touch with the general practice of clinical medicine and the means of
delivering health care to society. This will involve a new approach
to medical education and the establishment of many more training
The medical profession it
schemes for intermediate medical personnel.
self must be prepared to undertake the responsibility for planning the
training and the use of medical auxiliaries throughout the world.

* * * * *
These two articles are taken from a fascinating little volume, Health
manpower and the Medical Auxiliary, published by the Intermediate
Technology Development Group and reproduced here with its permission.
The complete book, which contains a foreword by Dr Maurice King and an
excellent bibliography, is available from the Intermediate Technology
Development Group Limited, 9 King Street, London UJC2E 8HN, England,
at the cost of £1.50.

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