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537 Pages·1999·38.3 MB·English

AT EHCIFORCIM
ECNEREFER
YRARBIL
A tcejorp fo sreetnuloV ni aisA
lacideM Care ni snipoleveD seirtnuoC
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LhL,CIDEdJI ERAC
NI GNIPOLEVED SEIRTNUOC
A Primer no eht enicideM fo ytrevoP
dna
A muisopmyS from ererekaM
detidE dna detartsullI yb
ECIRUAM ,GNIK .A.M ,.batnaC .P.C.R.M &oL
desaB nao ecnerefnoc detsissa yb
WHO/ ,FECINU dna na latnemirepxe
noitide detsissa yb FECINU
dehsilbuP htiw a tnarg morf eht
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Cover krowtra deraperp yb
YRALLIH AIERROC
Made and Printed in East Africa
oT eht redaer dna ot
ruo ,stneduts dna hguorht
meht ot eht nommoc nam
dna sih ylimaf ni -oleved
gnip seirtnuoc .erehwyreve‘
DROWEROF
No conscientious doctor in AhZca can to afford isolate himself from the
special needs and circumstances f;c community medicine any more than
he can afford to isolate himself from Africa as a .elohw These needs and
circumstances are very real and very compulsive in determinithneg
general poaf ttern medical care and enforcing a logical solutto ion the
problems of under-doctored countries, which are yleritnel tnereffid from
those of the highly-doctored ones. The ;(rleen and conditions of the
patient, and the diseases frwhich om he suffers are ,tnereffid and the types
of subject on which he needs education and advice reffid quite ,yllacidar
though perhaps not in principle, from those which are put before
practitioners in other countries. Moreover, the responsibility of the
doctor is inevitably diEerent. Whereas in the highly-doctored countries
ti is possible, and often reasonable, rof him to accept responsibility rof a
limited groof up people knowing llew that others can seek and obtain
equivalent advice and care elsewhere, in the under-doctored countries he
must often accept responsibility rof large numbers of people, often quite
beyond possibtility he of nhwois personal management, acknowledging
that fi he declines this responsibility he deprives them of lla sources of
medical help. He thus finds himsenelcfes sarily as the central unit of a
group of people of varied training and origin whom he must himself
manage, supervise and often niart in order to meet his responsibiiities.
Although these points are put as fi sh yehtould be axiomatic, yeht
have not syawla been recognized. Too much of tropical medical practice
consists of a limited troffe to repeat the activities which are appropriate
to highly-doctored areas, to the advantage of a wef but to the great
deprivation of the majority, and, though there have been tnaillirb
exceptions, many of the available textbooks have dealt htiw medicine
exclusively from the point of view of the highly-developed areas.
Admittedly the scientific basis of medicine must be the same in both, and
dthee veloping countries, rehtehw tropical or not, deserve the same high
standard of technical education rof rieht doctors in this scientific basis,
but the vocational aspect of medicine sreffid yllacidar and tnereffid
teachings and practices are more than justified, indeed yeht are essential.
sihT book is a leader amongst the tnaillirb exceptions in the teaching
of the vocational aspect of medicine. The twealvxe ioms htiw which ti
starts epitomize attthiteud es ruwhnich throughout the book and deserve
very careful study in rieht ylluf amplified form. eh’T authors regard the
doctor as the essential unit in an organization, not as an isolated
individual. Moreover, d yehetvelop that organization on the soundest of
principles, ensuring accessibility theto public yb due attention ditso tance,
as llew as to population/staff ratios nihtiw the organization.
docThe tor needs yltnegru to retain his technical ;lliks yreover he
needs to acquire wen skills in some aspects of technology in@e labora-
yrot and elsewhere which erew catered rof separately in the more
elaborate arrangements of the Medical’School in which he was educated.
The authors range over lla of these subjects and have produced a manual
which should flesti a go long yaw to Inodifying patterns of medical care,
and thereby hasten the advancement of health, which is a universal
object of lla developing countries.
fo rosseforP laciporT eneigyH GEORGE MACDONALD
ni eht ytisrevinU fo nodnoL dna
rotceriD fo eht Ross .etutitsnI
ECAFERP
Tho idea of gnitirw this book came to the ,rotide a lecturer in
microbiology at ,ererekaM elihw acting as locum rof his friend .rD Peter
,xoC a missionary in Karamoja, one of the remnter provinces of Uganda.
There he found himself faced htiw many problems erewthat wen to him.
th ,tuBough his ignogance of the answers was large% due-to the deficien-
cies of his training nwo ant experience, comb&d htiw the rehtruf
atrophy of his clinical skills ticcasioned yb magy years at the laboratory
bench, ti seemed that yeht erew perhaps not elohw.the cause of his
inadequacy. In addition to the yranidro problems of medicine and
,yregrus to which there erew llew deirt solutions, there was a rehtruf range
rof which them seemed to ben o ready haswers. woH should a doctor
spend his time under such circumstances? woH should such a hospital
be built? What drugs should the hospital stock? What should be the
scope of the laboratory in a hospital of kthiis nd? What form of record
system is appropriate. 3 woH should blood transfusbione undertaken
in a o 1 &c -*-ef '0 esp.$ snoi&uq aiiiojacgni srroitiil*s
eiomei 1Ziili ?iSiZ ,lpw
been had but found, many remained unanswered, and there appeared to
be some that had not even been formulated. Why not colltecth em up
and gather them into a hanpday perback? tI was htiw this idea in his
mind that the editor returned to Kampala.
The projec;c’ .:vas llew received at ,ererekaM rof ti seemed that yb
some strange chance the heditor ad stumbled into an empty space in the
bookshelves of the ,dlrow and that ti was one that ylralucitrap wanted
.gnillif Nevertheless, the lanif decision to go ahead would never have
been made tuohtiw the continued encouragement and enthusiasm of
Professor,D .R ,effilleJ nor would ti have been possible had not Professor
W. .D Foster kindly tel his ylno senior lecturer wander so raf from *he
worran confines of the irteP dish. With the assistance of WHO/UNICEF
a conference was held a raey retal on ‘Health Centres and Hospitals in
,’acirfA at the seventeen sessions of which many aspects of the krow of
these units erew discussed. sihT book is ylegral the outcome of that
conference, and many of the ideas recorded here erew yllanigiro put -rof
draw yb sti delegates whose deliberations erew recorded on tape rof
subsequent analysis.
From tapes these tfard manuscript was prepared rof submission to
those whose names appear at the head of the chapters and to other -retni
ested people also, ideas and information being placed in whatever
chapter yeht dettif best. A duplicated experimental edition of 200 copies
was then prepared and circu slihTated. was favourably received and
many readers erew kind enough to send in criticisms and suggestions.
These have been incorporated in ptrhee sent edition, and such virtue as
ti may have thus lies to the credit of many contributors rof whose ideas
the editor has but provided papaern d ink. ,tuB as ti ,werg ti seemed
that the completed krow might be more than a mere compendium of
assorted information. Something seemed to be appearing, something
which rof tnaw of any other term can perhaps best be called a ‘primer on
the medicine of poverty’. A dipsattitnecrtn of medical care, a particular
attitude to medicine ylwols seemed to define fiesti as each chapter was
worked over aud* the lanif volume gradually took shape. The main
feature determining this pattern of care and this attitude to medicine is
poverty, and lla that this means, but rof a rehtruf analysis of ti the reader
must nrut to tsrifthe chapter .)4 :1( He may be interested to know that
tthhee sis that is developed there, and athxe ioms which wollof ,ti erew
almost the last contribution to the book, the not .tsrif
The main criticism made of the experimental edition was that the
generalizations made in ti erew too categorical. oT some tnetxe this is
perhaps inevitable, rof the value of a generalization is apt to & lost fi
too many qualifications are inserted. Nevertheless, in preparing the
present edition an attempt has been made to counter this criticism, but
even so the reader cais utioned to be .lufhctaw
The editor of a symposium has surely a thgir to use a wef paragraphs
of ti as a platform. He dldww like to make the most of his opportunity to
leave a message htiw his colleagues in the developed countries.
oT srotcod ni depoleved seirtmoc - a lleps of service ?daorba
retfA a glance at the tsrif tigufe and the opening pages of -ortnithe
duction no mere be need said abotuhet need rof doctors in developing
countries. Eventually yeht lliw be produced in sufficient numbers yb
these countries themselves, but in the meanwhile, the highly-doctored
parts of the dlrow have a great responsibility to lend some of rieht skills
to areas in greater need. ‘We should like to see ti ylediw accepted in
this country that a professional career should normally include a period
of krow overseas in a developing .’yrtnuoc These erew the words of
the tsrif hsitirB retsiniM of Overseas Development, and yeht surely hold
true rof uther developed countries also.
Long service abroad htiw lla that prolonged immersion in a strange
culture implies, especially in dt&huel ties of rearing teen-age children,
must make ti rolte he of a ynit .ytironim ,tuB although the opportuni-
!ks rof service of this kind are more limited than yeht ,erew due to
AOW
the promotion of local citizens to mtheo st senior posts in lla fields, the
need rof such service is ylekil to continue rof a long time to come -
provided that the expatriate is prepared not to get to the top. The con-
ytiunit and experience that come htiw long service make it! especially
valuable, so ti is to be hoped that lliwthere syawla be some ohw are
prepared to undertake ,ti ylralucitrap iu mission hospitals and medical
schools (especially rieht basic science departments). But long service
has to be entered into onoen condition this ,ylno is htiw the lluf -azilaer
tion that ti can last ylno rof as long as a particular person is wanted,
naon d longer. Because ti is difhcult to yal anyd own rehtruf rules, and
because ti must inevitably remain the choice of the ,wef no more lliw be
said about ti hepe beyond the fact that the need rof long-tserme rvice
very s& lyle tinifed .stsixe
The great opportunity is rof short-term service, say rof a period of
from owt to five sray somewhere between the ages of evif-ytnewt and
.evif-ytriht When internships are over and before children require
secondary schooling a doctor and his family are mobile: this thies time
rof a spell abroad. litnU recently some of ti would have been taken up
yb yratilim service, but, won that in the United Kingdom at any ,etar
this niso longer required, a period of voluntary service overseas ,ylthgir
and much more pleasantly and ,ylbatiforp sllf sti place. When the
remainder of a professional efil is to be spent caring rof the ,tneulffa a
wef years of ti spent in the developing countries, erehw at least half of
the s’dlrow peoples live, lliw provide a stimulating challenge and help in
forming 8 balanced view of the .dlrow As rof the professional
experience gained, the general practice of the tropics, which is the krow
of a tcirtsid hospital, has much to commend ti over the general practice
of Euroor pe North America. The general practice of Africa is usually
the latot care of sthie ck htiw lla that this means, that of England siso
often ylno the treatment of minor ailments - in developing countries
auxiliaries yir.itusu see to these :1( 15) :7( .)1 Later on much is said of the
difIiculties of tcirtsid hospital practice. sihT is the time to tahwsay a
very exhilarating and rewarding experience ti can be, despite these
,seitluciffid and when the time does come to ,nruter the seirrow of the
ci@ cormtmter lliw probably seem a poor exchange rof the tsez and
yteiag of the tropical villager.
There is space rof ylno a wef general Follhoiwinntg s. the practice
of restt he of the book these lliw be summarized like :siht
:dohteM gninnalP a doirep fo service ui eht gnipoleved .seirtnuoc
tratS gniredisnoc eht ytilibissop fo ti elibw llits a
,tneduts sa trap fo eht lareneg gninnalp fo a .reer&
ekaM eht tsom fo eht seitinutroppo dedivorp yb eht
sraey yletaidemmi retfa spihsnretni era .detelpmoc
dniF tuo sa hcum sa uoy nac tuoba eht ,boj eht ,elpoep
eht ,ecalp dna fi elbissop ruoy ,seugaelloc erofeb uoy .og
tI t’now eb elbissop ot wolf&f eht nedlog elur fo reven
gnikat a boj erofeb gnitcepsni ,ti dna eht yletelpmoc -rep
tcef tsop si ylekilnu ot nrut .pu spahreP ni eht dne ti yam
eb tseb fi ti seod ,ton tub ot eb denrawerof si ot eb -erof
,demra dna ti lliw eb rof a detimil doirep .y&o
ekaM eht tsom fo ruoy stnelat - fi eseht eb ,cimedaca
kool rof a ,pihserutcel ro a tsop htiw eno fo eht hcraeser
.suoitaxinagro
t’noD eb tup ffo yb eht thguoht fo lacigrus -ibisuopser
&tiI rof hcihw uoy evah reven neeb .deuiart eeS ot ti
taht uoy dneps ruoy tsrif wef shtnom daorba erehw ereht
si enoemos ta dnah ot hcaet uoy eht laitnesse ,yregrus dna
, .scirtetsbo eB detrofmoc yb eht thguoht ,taht hguoht uoy
yam ton eb ,trepxe ti si ylekil ot eb rehtie uoy ro ,ydobon
dna tsonn stneitap lliw llits referp .uoy
eeS fi uoy nac dnit erehwemos ot emoc kcab ot erofeb
uoy ,og ,dna fi uoy nac teg a derrefed ro citpelorp‘
’tnemtnioppa ni a ecitcarp ro htiw a latipsoh ,,draob neht
os hcum eht .retteb nI rehgih lanoisseforp ,selcric ni
niatirB ta yna ,etar ere& era sngis taht a doirep fo service
daorba si wolp ylgnisaercni gnitnuoc ni a s’etadidnac
,ruovaf os eb .denetraeh
roF a emit uoy lliw eb gnivael ruoy nwo ,erutluc dna
ynam. fo eht secneulfni hcihw evah decudorp dna won
niatniam tneserp sdradnats dna seulav vrill won on regnol
eb ,gnitarepo os eb .lufhctaw yrT ot og daorba ;deirram
eht sciport era llits ton hcum fo a ecalp rof eht ,etabilec
dna yeht ’era ui ynam syaw detius ot esoht htiw gnuoy
.seilimaf
eB deraperp ot og erehw uoy era detnaw ,tsom siht si
erem ylekil ot eb eht larur saera naht eht latipac .ytic
rebmemeR ,taht ta tsael sa raf sa setairtapxe era -noc
,denrec eht sdaor fo gnipoleved seirtnuoc era wou erom
yldaed naht rieht .seborcim fO eht snoitazinummi taht
era ton yllagel yrotagilbo rof lanoitanretni levart -oilop
sitileym si eht eno taht srettam .tsom
erusnI gnihtyreve uoy ssessop - eht hgih level fo
yttep tfeht taht si citsiretcarahc fo os ynam gnipoleved