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Empire into commonwealth
(The previous number these Transactions, Vol. 55, No. 5. zoas published on 2nd October, 1961).
OPENING
MEETING
OF THE
FIFTY-FIFFH SESSSION
of the ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE
held at M a n s o n House, 26 Portland Place, London, W.1, on Thursday, 12th October, 1961
The President, SIR GEORGE MCROBERT, C.I.E., M.D., F.R.C.P., in the Cha/r.
PRESIDENTIAL ADDRESS
EMPIRE I N T O C O M M O N W E A I , T t I When the founder of this Society, Sir James Cantlie, became President he presented the fine badge which I now have the honour to wear. On it is inscribed the motto---Zonae Torridae Tutamen--Protection of the Torrid Zone. At first sight it might appear presumptuous for our Society to adopt such a motto, but we can proudly boast that the expectation of life in the tropies has been increased, and the secrets of many of its most dreaded diseases have been laid bare, by the work of Fellows of this Society. Much of the torrid zone has undergone great political change in the past few years. As the alteration in the status of many British overseas territories which has taken place is of prime interest to this Society, I have chosen " Empire into Commonwealth " as my subject, I spent thirty years in Asia in an exciting period when the training operations for the long planned grant of independence to India were being put into effect. The alteration in the world status of India in 1947 gave rise to a wave of unrest throughout our colonial empire, stimulating a demand for independence and national sovereignty throughout nearly all British dependencies with, in turn, a vigorous sympathetic movement in the oversea possessions of all European colonial powers. Independence granted to India was no sudden decision taken at the end of the war. From the earliest days of the British connexion with India it had been the intention of the British overlords to relinquish sovereignty at the end of a training period. In the middle of the last century Elphinstone wrote: " The most desirable death for us to die should be the improvement of the natives to such a pitch as would render it impossible for a foreign nation to retain the Government"; and in 1853, F. J. Halliday, Lieut-. Governor of Bengal, in his evidence to the House of Commons said: "I believe that our mission in India is to qualify them for governing themselves." When I gave British Council lectures in Portugal in 1951 on the subject of India I surprised my audience by quoting a series of such statesmanlike utterances and astonished
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them by stating that since 1921 Indian and Burmese councillors and ministers had absolute and complete control of health, education, land policy and certain other aspects of government, and that they were closely consulted and fully informed of all other branches of Government activities ; that there were Indian and Burmese Governors of major provinces, Indian Chief Justices of the High Courts, Indian Colonels in the Army, Indian Vice-Chancellors in the Universities, and that I myself in long service in the civil side of the Indian Medical Service had always worked under Burmese and Indian ministers, and that my College Principal at Madras was the now world-famous Sir Lakshmanaswami Mudaliar, later President and Chairman of the Executive Committee of the World Health Organization. With the passage of the Government of India Act in 1935, a further advance towards complete independence led to the final step in 1947 ; but we must realize that for many years the whole of what in this country constitutes the executive and clerical sections of the Civil Services were held by Indians and Burmans so that there was already in existence a highly trained and wholly indigenous administrative body of personnel, in addition to the Indian and Burmese members of the I.C.S. and other superior administrative services. The grant of independence to India and Burma triggered off demands from political leaders in the Colonies, without perhaps a realization of how difficult administration is and of how much it requires well-trained Civil Servants. From the evolution of India as a congeries of separate warring States to the present unified independent country, valuable lessons can be learned in many fields. Mistakes have been made which should be avoided in other emerging States. In reading of happenings in such new free countries the old servant of India has the feeling, familiar to readers of the works of Dunne or the plays of Priestley--we have been here before---old situations recur and old mistakes are made. I wish to spend a few minutes in tracing the evolution of the teaching of medicine in India. The civil branch of the I.M.S. was largely responsible for the introduction of modern science into India. Its earliest members took charge of the forests, developed agriculture, had charge of the botanical, zoological and marine biological surveys, directed the telegraph service, acted as chemical examiners to Government, and assayed the coinage at the Mint. Notwithstanding the excellent work done by the officers in the research department-work known to all of you, I maintain that it was in the educational field that the I.M.S. rendered its highest service to India. It is frequently forgotten that medical education plays a very important part in the general field of education---comprising, as it does, every branch of biological science plus physics and chemistry. I believe I am right in saying that neither in Montreal nor in Oxford was this realized by the planners and controllers of the Commonwealth Education Conferences, and that no medical educationalists, as such, were invited. It is to be hoped that this will be rectified before the next Conference in Delhi in 1962. It is a far cry from that day in 1664 when the Council at Fort St. George, now Madras, worried about the high death-rate amongst new recruits from England, decided "that in order that Englishmen might not be cast away like dogges for want of Christian charity, a hospital should be constructed within the fort." That was the origin of the Madras General Hospital, the mother of British overseas medical educational institutions which, with its 1,000 beds, 10 operation theatres, Nursing School and Institute of Radiology, with nine deep X-ray outfits, radium supply and radon plant, was unparalleled in Asia before 1939.
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In 1857 when the University Medical Faculties took over teaching from the pre-existing schools, all the professors were British. Ninety years later there were Indian professors in every branch of medicine and surgery. In direct consequence of the assumption by the British Government in 1857 of full sovereignty in India from the somewhat vague overlordship exercised previously by the East India Company, three universities were founded at Madras, Calcutta and Bombay in the eighteen fifties. From the earliest years it was intended that the standard aimed at in the medical faculties of their universities should in every way be equal to that obtaining in Great Britain. It followed, of course, that a comparatively restricted number of medical graduates of this calibre could be turned out. Few men were prepared to face seven years of university life and then go forth into the remote impoverished villages which still represent the real India. Provincial Governments continued then to maintain medical schools to which students could be admitted direct for a course lasting three years, at the end of which they became licensed medical practitioners (L.M.P.) who were able to deal with the run of ordinary medical cases, perform set operations such as ovariotomy, hernia, hydrocele and cataract with efficiency. Indeed, many distinguished and able district medical officers have confessed to me that in their earlier years in the districts, armed with Fellowships and much theoretical knowledge, they obtained their first real instruction and guidance in operative work from these unobtrusive doctor babus or sub-assistant surgeons. Apart from that t a r a at'is, ttle civil I.M.S. officer, there were therefore two grades of doctor in India: 1) The university graduate who could rise to be a district medical officer or professor; 2) The school licentiate--a permanent subordinate. As one of the principal doctor-exporting countries in the world, India sent her graduates and licentiates all over Asia, Malaya, South America and the West Indies. There inevitably developed a deep rooted jealousy, indeed hatred, between the two grades of doctor. Many licentiates were highly intelligent men, crowded out of the medical colleges on financial or caste-quota grounds. They entered politics--municipal, provincial and central--and soon became a force to be reckoned with. Many rose to high places. One of them was Dr. T. S. S. Rajan--a name probably unfamiliar to many of you ; but he was a key figure and was destined radically to change the pattern of medical education and practice not only in India but in the tropics generally. A study of his actions and motives is essential to anyone planning medical education in backward countries. T. S. S. Rajan originally trained as a licentiate in Madras, entered the subordinate medical service in Burma, resigned and came to England where he passed the English Conjoint examination. He entered politics as a member of the Congress party and became Minister of Health in Madras. By a stroke of the pen he abolished all licentiate medical schools by closing down all future entries. This included Dr. Ida Scudder's Vellore Medical School which had for years been turning out numbers of young medical women for village work. He gave orders that no research work should be carried out in hospitals, as the Government maintained a research department for that purpose, and hospital doctors were required to practise and teach generally accepted methods.
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Rajanization, as it was called, was copied by other Indian provinces. Medical schools were closed down wholesale and colleges training for university degrees have sprung up like mushrooms. Today in India and Burma the need for a doctor trained at less expense in time and money is again being canvassed, but we find that in discussing the provision of medical education facilities in some emergent countries especially in Africa, nothing short of the most modern buildings, with most expensively equipped laboratories and wards are acceptable, and that the provision of training of a lower grade is regarded by the Ministers as out of the question. This subject of two grades of instruction is a very important one. It is probable that a different answer will be found in different territories. We should avoid the jealousy and clash between two grades of doctor when possible; but is it really necessary to have the doctors taught to attain the London M.B. standard--notoriously the stiffest qualifying examination in Britain? Would not the Conjoint or Apothecaries standard do, at first? If we are to do away with the licentiate doctor, what about a medical technician comparable with the old Russian feldscher? Give him one or two years' practical training, with a modicum of theory, and he should be able to provide mass treatment, vaccinate, inoculate and report on public health matters, without demanding a high salary or becoming jealous of his medical superiors. Many of you have had experience in giving such training. I am sure there is room for it despite grandiose plans of the politicians. Hitherto dependent members of the Empire have at an increasing tempo achieved independence; some, like Burma, with no Commonwealth ties, while others like Nigeria and Sierra Leone continue to adhere to the Commonwealth. So rapidly is this development progressing that some find it difficult to believe that what, one month, was a territory in which they could inspect, advise or pay what they called "pastoral" visits, has become not only self-governing but has the option of sinking or swimruing as it so chooses, with the right, freely exercised, to ask anyone or everyone for financial or technical aid with the proviso, "no strings attached." One is not surprised that these newly-grown-ups tend to kick up their heels a little and to look around for fresh pastures to graze in: we have the experience that after a short time there are sometimes wistful looks over the old wall and an unconcealed desire to walk in line with the old shepherd. Even Members of Parliament and others who ought to know better do not always realize the difference between a Colony under direct or indirect control of the British Parliament and an independent country which has only diplomatic relations with Britain through the Commonwealth Relations Office, as Spain and Germany have through the Foreign Office. In otherwise welMnformcd and often exalted circles one not infrequently hears such expressions as "Nigeria has passed from the Control of the Colonial Office to be under the wing of the Commonweahh Relations Office." This is an absolute travesty of the truth. No independent country is under the wing of the Commonweahh Relations Office, or of anyone else. The prevalent combination of profession of independence, with willingness to beg for help, is a new phenomenon in world politics deriving from the two-ways division of the world, and we have to exercise the greatest tact in dealing with newly independent territories in order not to appear to impugn their new status or otherwise to offend their new-found dignity.
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In dealing with current problems we must have an acute appreciation of the truth uttered recently by Lord Alport, until the other day Minister of State for Commonwealth Relations: " Any attempt by the United Kingdom, however wise and far-sighted and commonsensed may be our motives, to carry the colonial apparatus forward into the era of independence is likely to be self-defeating." Two recent British moves to render tactful aid are of interest to this Society : 1) Tile formation, even in a time of severe financial stringency, of an entirely new Ministry--The Department of Technical Co-operation. You will note that the title of the new department implies Technical Co-operation-not merely technical assistance. The object is to do what we can, after in~.itation of the country concerned, to work with their own experts. The new Secretary for Technical Co-operation is the Rt. Hon. Dennis Vosper, formerly, and appropriately, Minister of Health, and the Permanent Head or Director-General Sir Andrew Cohen, formerly and equally appropriately a British Representative at United Nations Headquarters. 2) The other major step which interests us is the formation of the Tropical Medicine Research Board under the aegis of the Medical Research Council with its Secretary, Sir Harold Himsworth, as Chairman, and Professor Frazer of Birmingham as ViceChairman. The appointment of a man of Sir Harold's standing and capacity to this post augurs well for the quality of help Britain is prepared to go on giving, if she is invited to do so. The task facing us is to determine which are the most important priorities--how is available aid to be allocated? There is a political maxim which must be accepted by all who hold up ballot-box democracy as their political ideal and aim--It is that Truth--even in Science--shall not prevail till the Vote is secured and Independence is achieved. A short time ago a leader in West Africa denounced the cutting out of diseased cocoa trees to stop the spread of disease, as a brutal British outrage. Today he enforces the method with rigour. As late as 1946, with complete independence just round the corner, the Health Ministers of India, assembled in Delhi, urged the immediate abolition of the I.M.S., and reversion to the ages-old traditional Ayurvedic system of medicine. Now the Director of Health Services in India is a former I.M.S. officer. In Nyasaland control of smallpox by vaccination has been denounced by African politicians, and the disease spread like wildfire. After the attainment of independence doubtless the value of the most potent prophylactic known to medicine will again be appreciated. We must simply accept this fact and exercise patience. In talking to many laymen and to most medical men I find that there is a tendency to regard hospitals and practising doctors as a top priority for the technical aid programme for emergent tropical nations. I myself shall be very surprised if a high priority is given to therapeutic medicine. From our experience in dealing with Colombo Plan aid to South-East Asia--from Pakistan to the Philippines---we find that just over 12 per cent. of the 4,000 trainees sent to this country are from the medical and allied fields, and that a similar low priority is given to medicine in the sphere of capital equipment supplied. Even in that limited field I regret
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to say that the material asked for is often of the prestige variety---complicated, expensive and difficult to maintain, such as cobalt bombs and electron microscopes. The British Government have tried to confine Colombo Plan requests for training in the medical field to future teachers and researchers. In my own experience the most rewarding trainees have been those who have already reached a fair or even high degree of competence in their own special fields, and have come to bring themselves up to date in new techniques. I regret to say that many overseas trainees do not seem so much to desire real training as to acquire so-called "higher qualifications." The first need for any nation is peace and security. Little good does it do to a farmer if his ripening crop is carried off by raiders or his granary robbed by lawless bands. To reap what he has sown and to enjoy a fair proportion of what he has gathered in, is all that most peasants hope for and very few obtain. Agriculture, irrigation and primary education are the top priorities; but in the tropics general debility of man and beast from preventable disease is so prevalent that preventive medicine must loom large to the donors of aid. A very high proportion of such prevalent diseases of man and animal are well understood and preventive measures are available. But there is still need for further research. Until recently it was generally believed that the malaria parasite lived in the human body in the red corpuscles only; it was thought that the filariae which affected the human frame differed from those found in animals; and we were of opinion that yellow fever was a disease of man only. All these beliefs have been upset within the past few years by research workers. It is very urgent that such research should continue at high pressure by personnel really trained and competent to tackle the difficult problems involved. Of all the fields of research open to the medical worker in the tropics, top priorities must be given to problems of nutrition and family limitation. It is only after adequate laboratory and field research into the multifarious problems of absorption, interaction and utilization of various food fractions and accessory food factors that the agriculturist, pisciculturist and stock farmer can set about providing the recommended cheap sources of protein and protective foods. To Robert McCarrison we must pay tribute because, although not a trained scientist, he early realized and insisted on the supreme importance of research into well-balanced and protective diets, and on the provision of nutritional research institutes on the lines of his pioneering laboratories in Coonoor. With the teeming multitudes increasing with explosive force and living longer on account of our ministrations, there is much truth in the aphorism, an atomic bomb is not so dangerous as the Anatomic Womb; and the need for wide-spread instruction in cheap and safe contraceptive methods is almost paramount in its urgency. Tubo-ligation and vaso-ligation have become popular among well-to-do classes in India and Burma, but that does not touch the fringe of the problem. It is surprising how little the average doctor coming from the tropics knows about this problem. The Colombo Plan authorities have provided much help through the medium of the Family Planning Association. In the West African Medical Journal there appeared last year a remarkable article by Dr. G. M. Bull, Professor of Medicine at Belfast. After a tour of Nigeria, made at the invitation of the Nigerian Government, he published his recommendations. From any
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medical man they would be remarkable. Coming from a whole-time bedside teacher of medicine they are surprising. His thesis is arresting and deliberately provocative-It is that the National income of Nigeria cannot support a standard of hygiene and medical care equal to that obtaining in Britain ; that the first priority is to increase national income; that communications, agriculture and education are the items of outstanding importance; and that anything spent on health should, if possible, have the additional aim of improving national income. He points out that the increased expectation of life in Britain is due to public health measures, good water supplies, improvement in diets, housing and drainage, and that public health schemes are cheaper in the long run and infinitely more effective than curative medicine. He recommends that for many years to come expenditure on health should be kept at a minimum lest it delay other more important developments, and that at the present time curative medicine is a luxury which at present must be dispensed very sparingly. At the present time in Nigeria six times more is spent on curative than on preventive medicine. Bull recommends that preventive medicine should receive at least two-thirds of money available for health schemes. These are harsh words and grim, but is there not much truth in them? A compounder or dresser with a few shillings worth of chloroquine and sulpha pills can render more valuable relief than a member of the Royal College of Physicians with thousands of pounds worth of electronic equipment ; and his vaccination lancet and inoculation syringe would do so much more good in preventing suffering. For vote getting and other political reasons a large hospital with marble halls has a stronger appeal than a piped water s u p p l y - and, incidentally, I often wonder if those purveyors of marble halls are aware of the sterling work performed during the past hundred years or more at places like Calicut, the spot at which Vasco da Gama first landed in India, where the district hospital consisted of little more than wattle walls and a roof of local tiles - - b u t within those walls fine advanced surgery was carried o u t ; indeed, within them Fraser worked out his technique for ureter-implantation in the bowel which has put an end to so much suffering from vesico-vaginal fistula. Do gigantic modern hospitals really have a high priority ? Does such an imposing structure as Ibadan hospital with its huge drain on national finances really justify itself ? Does anyone who has visited the sheds at Shikarpur where our outstanding missionary surgeon, Sir Henry Holland, performed such prodigious feats of ophthalmic surgery, doubt that a man with a will is still what matters most ? Expensive equipment can be dispensed with as a high priority in backward countries. In contrast to Professor Bull's thesis we have the recommendation of another British professor of medicine who urged the supply to hospitals in South-East Asia of numbers of Melrose Heart-Lung pumps to boost British prestige, and to relieve the effects of congenital heart disease. The Colombo Plan authorities took the trouble to send a team of experts from Hammersmith to visit a capital in South-East Asia and to estimate the expenditure necessary to train and equip one specialist team for modern cardiac surgery. The estimate was £40,000. We are really in a terrible dilemma. Money is limited. Are we to cure or alleviate relatively rare conditions requiring expensive apparatus, or to use our money for the prevention and alleviation of mass suffering ?
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It is most important that Ministers of Health should be well-educated men with a knowledge of science and with balanced judicial minds and that their technical advisers - the Directors of Health Services - - should be men with leanings to the preventive side, but with an all-round knowledge of medicine. In India we made one gigantic mistake which I am glad to say the present Government of India has rectified. In the Central Government and in the provinces therapeutic medicine and hospital administration were dealt with separately from the preventive and hygiene side. The Director-General and the Public Health Commissioner dealt separately with their subjects, the Inspectors General of Hospitals and the Directors of Public Health were heads of their own departments and gave individual and often differing advice to their Ministers. But the Hospital men had the higher rank, and it was a matter of promotion for a Director of Public Health to become a hospital inspector. This was obviously wrong and should never be repeated. In South-East Asia the White Elephant is a sacred object. The gift of it by a prince to a subject was more often than not an acute embarrassment to him, as it ate him out of house and home and required constant care from a host of attendants. Let us not embarras the new countries with gifts of White Elephants in the shape of gigantic hospitals, coloured television apparatus, electron microscopes and other advanced specialized equipment. Sir Andrew Balfour who did so much for tropical medicine used to refer to the benefit of a touch of snow on the mental powers. The highest grade of research work can be carried out only in cool invigorating climates : air-conditioning is not an adequate substitute. Two kinds of research worker are needed. High-power workers in temperate climates and well-trained competent workers for prolonged periods in the tropics. These men must have security of tenure and long-term prospects of employment guaranteed by a stable government. The former type should, however, visit the tropical scene of operations at intervals so as to keep in touch with actuality. The day of the general scientific practitioner has gone. In its time it yielded wonderful results. I recollect my friend Henry S h o r t t - one of our former P r e s i d e n t s - when at the King Institute near Madras conducting simultaneously experiments on the malaria parasite, the virus of sandfly fever and dengue, on the fluorine content of water and its effect on skeletal structure, on the therapeutic value of a leishmania vaccine prepared from cultures obtained from the nasal mucosa, and on certain aspects of snake venom therapy. The I.M.S. officer like Habbakuk was said to be capable de tout, but during the past decade laboratory techniques have changed so greatly that the scientific g.p. is a back number. There is increasing room for international co-operation in the tropical field of research. We are all aware, I hope, of the story of Kyasanur Forest disease - - of the discovery of its cause and course and of the preparation of an effective vaccine within a matter of months of the first cases of a mysterious disease being reported from Mysore State - - International co-operation was then seen at its best. It would be appropriate here to draw your attention to the work being carried out in Madras during the past few years on the domiciliary treatment of tuberculosis. The findings have been startling and indeed revolutionary, for they tend to show that patients with pulmonary tuberculosis can be treated as effectively and safely in their homes as in h o s p i t a l - that specific drugs given once a day may be as effective as if administered three times a day with meals according to tradition, that patients can be treated without ceasing work, and that it is not so much the open case as the undetected case that is dangerous.
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There is an outstanding example of International Co-operation in R e s e a r c h - the participants being the Madras Government, the World ttealth Organization, the Indian Council of Medical Research and the Medical Research Council of Great Britain. The work is by no means complete but it is obvious that results of the highest importance for all countries of the world are emerging. For the success of such schemes good faith between subscribing bodies is essential and support promised at the beginning by a country or State must be given right through to the end. During our years in India, relations between British workers in the research and hygiene fields and those of the International Health Division of the Rockefeller Foundation were not only friendly but were cordial and complementary. The Rockefeller workers, like the British, had the security of continuous pensionable sen.ice. In the University of Rangoon where the two constituent colleges - - British and American (University College and Judson C o l l e g e ) - faced each other on the same c a m p u s - the mutual love and affection enjoined on us by William Harvey were much in evidence. The attitude of the American press has not always been friendly to us and American publishers have sought to give an anti-British slant in their books, but fortunately this has not affected relations between British and American field workers, and it is of supreme importance that scientific workers in the tropical field from both sides of the Atlantic should retain their bonds of esteem and friendship. My main thesis is that a high proportion of money available for aid in the health field from British sources should be spent on British-based research, and that most of the remainder should be directed into the field of health education. One often hears the question asked : " Why not leave all this to the World Health Organization " ? - - t h e most conspicuously successful part of United Nations activities. The World Health Organization has been a powerful factor for good in underdeveloped countries, its work in the fields of malaria and yaws control deserving special mention ; but as the late Secretary-General, Mr. Hammarskjold, reminded us, he was constantly being worried by demands for staff appointments to be made on a strict national-proportional-representation basis. This inevitably leads to diminished efficiency and to short-term contracts. We gladly pay our share of W t t O expenditure, but we owe it to our partners in the Commonwealth to provide dependable sustained long-term aid. There exists in this country among all peoples and all parties a general desire to help emerging independent countries. What can we do ? The first essential is tact, sympathy and a sense of proportion. Secondly : Britain must set a better example in the working of our National Health Service. It is a fine service, well conceived and it got off to a good start. It is being closely studied by overseas governments, both friendly and unfriendly, and must not be allowed gradually to drift, as it is doing, into a service which it is not quite proper for an educated or moderately well-off person to use if he or she can possibly scrape up the money or insurance premium to avoid doing so. Thirdly : we must ensure that the large army of young clinicians who come from abroad to get further training and experience here are not merely used as hands, but that the consultants under whom they work give up a substantial amount of their time to teaching
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and supervising them. There should be no such thing as a non-teaching hospital or a non-teaching consultant. A senior teacher from Britain who recently returned from a visit to India said he was shocked to find the number of clinical professors and lecturers in that country whose only contact with hospital work in Britain was in remote and obscure hospitals in minor industrial centres. Fourthly : we must make more provision for laboratory training for workers from the tropics. There is a great shortage of medical laboratory workers in Asia and A f r i c a - welltrained bacteriologists and virologists capable of running vaccine and serum-producing plant are at a premium, and training vacancies in this country are woefully insufficient. There are ample arrangements for diploma work in tropical medicine and hygiene and for the diplomas in public health and industrial hygiene ; but in morbid anatomy, clinical pathology and bacteriology the availability of diploma courses bears no relation to the demand. Many of us deplore the status given abroad to the diploma holder and the insistent demands by certain governments for training ending in the award of a parchment. Diplomas do serve in many areas as a guard against nepotism : the deplorable fact is that the laboratories of many undergratuate hospitals whose teachers have the benefits of the higher emoluments deriving from association with the National Health Service take no part in providing instruction in laboratory subjects at an advanced level for postgraduates from abroad. Some outlying provincial hospitals are giving commendable aid in this matter, and I must pay tribute to help given by the National Laboratory Service and its Director, Dr. G. S. Wilson. One of the principal ways in which our universities can help is by giving places for training to young doctors in the basic medical sciences of anatomy, physiology and biochemistry. There is a great shortage of teachers in these subjects and quite a number come here aiming at the Ph.D. It is better to put them through an honours B.Sc. course and to add a year at pure research at the end of it. I have seen some most gratifying results from t h i s - When a Ph.D. is insisted on, some universities make their syllabus elastic so as to enable the candidate to combine the honours B.Sc. syllabus with preparation of a Ph.D. thesis if a registrable medical degree is held. Sound training in the basic principles of science is one thing we can afford to give to overseas graduates, and is very necessary in order to combat superstition and traditional methods of the older generation in India and elsewhere. Fifthly : our medical schools must continue to allot a number of undergraduate places to Commonwealth students, especially to those countries which have not yet got facilities for such training. A recent survey showed that schools in Britain allotted from 4 to 9 per cent. of their undergraduate vacancies to such men and women. This may be considered to be a generous proportion in view of the number of wellqualified and keen young British applicants who are thereby excluded : but I must plead not only for a continuance of this facility, but for an increase in oversea intake even if it means opening up yet another medical school in Exeter, Plymouth or some such city. Finally : The Tropical Medicine Research Board must get real support. The two schools of tropical medicine in this country have done sterling work in the past by maintaining workers for prolonged periods overseas and by frequent short expeditions. The
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laboratories run by the M.R.C. in the Gambia and the institutions supported by interterritorial schemes in the colonial past have played an important part in advancing the state of medicine in the tropics up to the present time. The present influence of the Liverpool School which has resulted in notable foundations in Thailand and Ghana is very considerable, and Maegraith's dynamic energy is appreciated over a wide field. I am sure that after what may be a latent p e r i o d - long or s h o r t - the resources of our great institutions in this country will through the mediation of the Tropical Medicine Research Board play a full part in maintaining British influence in the future. I am not so sure of the advantages to be gained by the so-called " pastoral visits of consultants overseas to keep doctors in touch with new developments. It is sometimes forgotten that one can keep in touch by reading the literature. In the old days one could depend on having the top men available here all the year round except in August. It is becoming increasingly frequent for men from abroad to find on arrival here that the teachers at whose feet they have come to sit are in Honolulu, San Francisco or Sydney-especially from November to March. I can however vouch for the great benefit conferred by prolonged visits to overseas medical schools of teams of clinical teachers, such as that sent to India in 1955 by invitation under the Colombo Plan where the members worked in the wards and operation theatres for not less than three weeks in any particular institute and got down to basic teaching at the bedside. The Rosenheim mission is still talked of with bated breath in India. A repeat performance has been asked for and Pakistan wants parity. The recent teaching mission of Professor Last of the Royal College of Surgeons to Pakistan and Burma has been, it is reported, a revelation of what good teaching can be. In our relations with other countries we are sometimes embarrassed by requests which imply that our medical profession is not independent and that our learned colleges and institutions are subordinate to the Minister of Health. Our Government is from time to time asked to draft doctors from the National Health Service for work in newly independent territories. They have no power to do so. In treaty negotiations between Britain and foreign Governments it is not unusual for our Government to be asked to put pressure on the General Medical Council to recognize foreign degrees and diplomas. These Governments are astonished when they are informed that no such powers of compulsion exist. The independent medical profession is anxious and willing to give help, but requires guidance into the most appropriate fields. The new consultative committee chosen from leaders of the profession to advise the Minister for Technical Co-operation should, from its composition, be a guarantee to the profession that the best possible advice will be given. From my own experience of finding adventurous young men and women to go to such out-of-the-way and even dangerous fields as Laos, I am confident that doctors are still to be found here to venture forth to give a helping hand, if only employing bodies will give them some credit for their spirit and initiative on their return. I commenced this address with a reference to Sir James Cantlie, our founder. One of his main claims to fame is that he played a notable part in changing the course of the history of the world. Winston Churchill tells us that " it is always being changed by something" ; but the fact is that it was solely due to Cantlie's importunity and persistence that Lord Salisbury, "
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the British Prime Minister, was persuaded to secure the release of a Chinese political worker who had been kidnapped from the streets of London into the cellars of the Chinese Embassy, there to await transportation to China for execution. The victim was Sun Yat Sen, the founder of modern China. Years later, in 1923, as Professor Lancelot Forster has recently reminded us, Dr. Sun Yat Sen returned to the University of Hong Kong, and addressing the staff and students said : When I was studying in Hong Kong I compared my home in Heung Shan with Hong Kong, and though only fifty miles apart the difference in Government oppressed me very much. I began to wonder how it was that Englishmen could do such things as they had done with the barren rock of Hong Kong within 70 or 80 years while in 4,000 years China had no place like Hong Kong. You and I have studied in the English colony and in an English university, and we must learn by English examples. We must carry this English example to every part of China." "
Sun Yat Sen's call to his people to follow the English example will, we hope, continue to echo throughout the world so long as our country and our Society live up to the motto ZONAE TORRIDAE TUTAMEN.
OPENING
MEETING
OF THE
FIFTY-FIFFH SESSSION
of the ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE
held at M a n s o n House, 26 Portland Place, London, W.1, on Thursday, 12th October, 1961
The President, SIR GEORGE MCROBERT, C.I.E., M.D., F.R.C.P., in the Cha/r.
PRESIDENTIAL ADDRESS
EMPIRE I N T O C O M M O N W E A I , T t I When the founder of this Society, Sir James Cantlie, became President he presented the fine badge which I now have the honour to wear. On it is inscribed the motto---Zonae Torridae Tutamen--Protection of the Torrid Zone. At first sight it might appear presumptuous for our Society to adopt such a motto, but we can proudly boast that the expectation of life in the tropies has been increased, and the secrets of many of its most dreaded diseases have been laid bare, by the work of Fellows of this Society. Much of the torrid zone has undergone great political change in the past few years. As the alteration in the status of many British overseas territories which has taken place is of prime interest to this Society, I have chosen " Empire into Commonwealth " as my subject, I spent thirty years in Asia in an exciting period when the training operations for the long planned grant of independence to India were being put into effect. The alteration in the world status of India in 1947 gave rise to a wave of unrest throughout our colonial empire, stimulating a demand for independence and national sovereignty throughout nearly all British dependencies with, in turn, a vigorous sympathetic movement in the oversea possessions of all European colonial powers. Independence granted to India was no sudden decision taken at the end of the war. From the earliest days of the British connexion with India it had been the intention of the British overlords to relinquish sovereignty at the end of a training period. In the middle of the last century Elphinstone wrote: " The most desirable death for us to die should be the improvement of the natives to such a pitch as would render it impossible for a foreign nation to retain the Government"; and in 1853, F. J. Halliday, Lieut-. Governor of Bengal, in his evidence to the House of Commons said: "I believe that our mission in India is to qualify them for governing themselves." When I gave British Council lectures in Portugal in 1951 on the subject of India I surprised my audience by quoting a series of such statesmanlike utterances and astonished
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them by stating that since 1921 Indian and Burmese councillors and ministers had absolute and complete control of health, education, land policy and certain other aspects of government, and that they were closely consulted and fully informed of all other branches of Government activities ; that there were Indian and Burmese Governors of major provinces, Indian Chief Justices of the High Courts, Indian Colonels in the Army, Indian Vice-Chancellors in the Universities, and that I myself in long service in the civil side of the Indian Medical Service had always worked under Burmese and Indian ministers, and that my College Principal at Madras was the now world-famous Sir Lakshmanaswami Mudaliar, later President and Chairman of the Executive Committee of the World Health Organization. With the passage of the Government of India Act in 1935, a further advance towards complete independence led to the final step in 1947 ; but we must realize that for many years the whole of what in this country constitutes the executive and clerical sections of the Civil Services were held by Indians and Burmans so that there was already in existence a highly trained and wholly indigenous administrative body of personnel, in addition to the Indian and Burmese members of the I.C.S. and other superior administrative services. The grant of independence to India and Burma triggered off demands from political leaders in the Colonies, without perhaps a realization of how difficult administration is and of how much it requires well-trained Civil Servants. From the evolution of India as a congeries of separate warring States to the present unified independent country, valuable lessons can be learned in many fields. Mistakes have been made which should be avoided in other emerging States. In reading of happenings in such new free countries the old servant of India has the feeling, familiar to readers of the works of Dunne or the plays of Priestley--we have been here before---old situations recur and old mistakes are made. I wish to spend a few minutes in tracing the evolution of the teaching of medicine in India. The civil branch of the I.M.S. was largely responsible for the introduction of modern science into India. Its earliest members took charge of the forests, developed agriculture, had charge of the botanical, zoological and marine biological surveys, directed the telegraph service, acted as chemical examiners to Government, and assayed the coinage at the Mint. Notwithstanding the excellent work done by the officers in the research department-work known to all of you, I maintain that it was in the educational field that the I.M.S. rendered its highest service to India. It is frequently forgotten that medical education plays a very important part in the general field of education---comprising, as it does, every branch of biological science plus physics and chemistry. I believe I am right in saying that neither in Montreal nor in Oxford was this realized by the planners and controllers of the Commonwealth Education Conferences, and that no medical educationalists, as such, were invited. It is to be hoped that this will be rectified before the next Conference in Delhi in 1962. It is a far cry from that day in 1664 when the Council at Fort St. George, now Madras, worried about the high death-rate amongst new recruits from England, decided "that in order that Englishmen might not be cast away like dogges for want of Christian charity, a hospital should be constructed within the fort." That was the origin of the Madras General Hospital, the mother of British overseas medical educational institutions which, with its 1,000 beds, 10 operation theatres, Nursing School and Institute of Radiology, with nine deep X-ray outfits, radium supply and radon plant, was unparalleled in Asia before 1939.
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In 1857 when the University Medical Faculties took over teaching from the pre-existing schools, all the professors were British. Ninety years later there were Indian professors in every branch of medicine and surgery. In direct consequence of the assumption by the British Government in 1857 of full sovereignty in India from the somewhat vague overlordship exercised previously by the East India Company, three universities were founded at Madras, Calcutta and Bombay in the eighteen fifties. From the earliest years it was intended that the standard aimed at in the medical faculties of their universities should in every way be equal to that obtaining in Great Britain. It followed, of course, that a comparatively restricted number of medical graduates of this calibre could be turned out. Few men were prepared to face seven years of university life and then go forth into the remote impoverished villages which still represent the real India. Provincial Governments continued then to maintain medical schools to which students could be admitted direct for a course lasting three years, at the end of which they became licensed medical practitioners (L.M.P.) who were able to deal with the run of ordinary medical cases, perform set operations such as ovariotomy, hernia, hydrocele and cataract with efficiency. Indeed, many distinguished and able district medical officers have confessed to me that in their earlier years in the districts, armed with Fellowships and much theoretical knowledge, they obtained their first real instruction and guidance in operative work from these unobtrusive doctor babus or sub-assistant surgeons. Apart from that t a r a at'is, ttle civil I.M.S. officer, there were therefore two grades of doctor in India: 1) The university graduate who could rise to be a district medical officer or professor; 2) The school licentiate--a permanent subordinate. As one of the principal doctor-exporting countries in the world, India sent her graduates and licentiates all over Asia, Malaya, South America and the West Indies. There inevitably developed a deep rooted jealousy, indeed hatred, between the two grades of doctor. Many licentiates were highly intelligent men, crowded out of the medical colleges on financial or caste-quota grounds. They entered politics--municipal, provincial and central--and soon became a force to be reckoned with. Many rose to high places. One of them was Dr. T. S. S. Rajan--a name probably unfamiliar to many of you ; but he was a key figure and was destined radically to change the pattern of medical education and practice not only in India but in the tropics generally. A study of his actions and motives is essential to anyone planning medical education in backward countries. T. S. S. Rajan originally trained as a licentiate in Madras, entered the subordinate medical service in Burma, resigned and came to England where he passed the English Conjoint examination. He entered politics as a member of the Congress party and became Minister of Health in Madras. By a stroke of the pen he abolished all licentiate medical schools by closing down all future entries. This included Dr. Ida Scudder's Vellore Medical School which had for years been turning out numbers of young medical women for village work. He gave orders that no research work should be carried out in hospitals, as the Government maintained a research department for that purpose, and hospital doctors were required to practise and teach generally accepted methods.
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Rajanization, as it was called, was copied by other Indian provinces. Medical schools were closed down wholesale and colleges training for university degrees have sprung up like mushrooms. Today in India and Burma the need for a doctor trained at less expense in time and money is again being canvassed, but we find that in discussing the provision of medical education facilities in some emergent countries especially in Africa, nothing short of the most modern buildings, with most expensively equipped laboratories and wards are acceptable, and that the provision of training of a lower grade is regarded by the Ministers as out of the question. This subject of two grades of instruction is a very important one. It is probable that a different answer will be found in different territories. We should avoid the jealousy and clash between two grades of doctor when possible; but is it really necessary to have the doctors taught to attain the London M.B. standard--notoriously the stiffest qualifying examination in Britain? Would not the Conjoint or Apothecaries standard do, at first? If we are to do away with the licentiate doctor, what about a medical technician comparable with the old Russian feldscher? Give him one or two years' practical training, with a modicum of theory, and he should be able to provide mass treatment, vaccinate, inoculate and report on public health matters, without demanding a high salary or becoming jealous of his medical superiors. Many of you have had experience in giving such training. I am sure there is room for it despite grandiose plans of the politicians. Hitherto dependent members of the Empire have at an increasing tempo achieved independence; some, like Burma, with no Commonwealth ties, while others like Nigeria and Sierra Leone continue to adhere to the Commonwealth. So rapidly is this development progressing that some find it difficult to believe that what, one month, was a territory in which they could inspect, advise or pay what they called "pastoral" visits, has become not only self-governing but has the option of sinking or swimruing as it so chooses, with the right, freely exercised, to ask anyone or everyone for financial or technical aid with the proviso, "no strings attached." One is not surprised that these newly-grown-ups tend to kick up their heels a little and to look around for fresh pastures to graze in: we have the experience that after a short time there are sometimes wistful looks over the old wall and an unconcealed desire to walk in line with the old shepherd. Even Members of Parliament and others who ought to know better do not always realize the difference between a Colony under direct or indirect control of the British Parliament and an independent country which has only diplomatic relations with Britain through the Commonwealth Relations Office, as Spain and Germany have through the Foreign Office. In otherwise welMnformcd and often exalted circles one not infrequently hears such expressions as "Nigeria has passed from the Control of the Colonial Office to be under the wing of the Commonweahh Relations Office." This is an absolute travesty of the truth. No independent country is under the wing of the Commonweahh Relations Office, or of anyone else. The prevalent combination of profession of independence, with willingness to beg for help, is a new phenomenon in world politics deriving from the two-ways division of the world, and we have to exercise the greatest tact in dealing with newly independent territories in order not to appear to impugn their new status or otherwise to offend their new-found dignity.
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In dealing with current problems we must have an acute appreciation of the truth uttered recently by Lord Alport, until the other day Minister of State for Commonwealth Relations: " Any attempt by the United Kingdom, however wise and far-sighted and commonsensed may be our motives, to carry the colonial apparatus forward into the era of independence is likely to be self-defeating." Two recent British moves to render tactful aid are of interest to this Society : 1) Tile formation, even in a time of severe financial stringency, of an entirely new Ministry--The Department of Technical Co-operation. You will note that the title of the new department implies Technical Co-operation-not merely technical assistance. The object is to do what we can, after in~.itation of the country concerned, to work with their own experts. The new Secretary for Technical Co-operation is the Rt. Hon. Dennis Vosper, formerly, and appropriately, Minister of Health, and the Permanent Head or Director-General Sir Andrew Cohen, formerly and equally appropriately a British Representative at United Nations Headquarters. 2) The other major step which interests us is the formation of the Tropical Medicine Research Board under the aegis of the Medical Research Council with its Secretary, Sir Harold Himsworth, as Chairman, and Professor Frazer of Birmingham as ViceChairman. The appointment of a man of Sir Harold's standing and capacity to this post augurs well for the quality of help Britain is prepared to go on giving, if she is invited to do so. The task facing us is to determine which are the most important priorities--how is available aid to be allocated? There is a political maxim which must be accepted by all who hold up ballot-box democracy as their political ideal and aim--It is that Truth--even in Science--shall not prevail till the Vote is secured and Independence is achieved. A short time ago a leader in West Africa denounced the cutting out of diseased cocoa trees to stop the spread of disease, as a brutal British outrage. Today he enforces the method with rigour. As late as 1946, with complete independence just round the corner, the Health Ministers of India, assembled in Delhi, urged the immediate abolition of the I.M.S., and reversion to the ages-old traditional Ayurvedic system of medicine. Now the Director of Health Services in India is a former I.M.S. officer. In Nyasaland control of smallpox by vaccination has been denounced by African politicians, and the disease spread like wildfire. After the attainment of independence doubtless the value of the most potent prophylactic known to medicine will again be appreciated. We must simply accept this fact and exercise patience. In talking to many laymen and to most medical men I find that there is a tendency to regard hospitals and practising doctors as a top priority for the technical aid programme for emergent tropical nations. I myself shall be very surprised if a high priority is given to therapeutic medicine. From our experience in dealing with Colombo Plan aid to South-East Asia--from Pakistan to the Philippines---we find that just over 12 per cent. of the 4,000 trainees sent to this country are from the medical and allied fields, and that a similar low priority is given to medicine in the sphere of capital equipment supplied. Even in that limited field I regret
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to say that the material asked for is often of the prestige variety---complicated, expensive and difficult to maintain, such as cobalt bombs and electron microscopes. The British Government have tried to confine Colombo Plan requests for training in the medical field to future teachers and researchers. In my own experience the most rewarding trainees have been those who have already reached a fair or even high degree of competence in their own special fields, and have come to bring themselves up to date in new techniques. I regret to say that many overseas trainees do not seem so much to desire real training as to acquire so-called "higher qualifications." The first need for any nation is peace and security. Little good does it do to a farmer if his ripening crop is carried off by raiders or his granary robbed by lawless bands. To reap what he has sown and to enjoy a fair proportion of what he has gathered in, is all that most peasants hope for and very few obtain. Agriculture, irrigation and primary education are the top priorities; but in the tropics general debility of man and beast from preventable disease is so prevalent that preventive medicine must loom large to the donors of aid. A very high proportion of such prevalent diseases of man and animal are well understood and preventive measures are available. But there is still need for further research. Until recently it was generally believed that the malaria parasite lived in the human body in the red corpuscles only; it was thought that the filariae which affected the human frame differed from those found in animals; and we were of opinion that yellow fever was a disease of man only. All these beliefs have been upset within the past few years by research workers. It is very urgent that such research should continue at high pressure by personnel really trained and competent to tackle the difficult problems involved. Of all the fields of research open to the medical worker in the tropics, top priorities must be given to problems of nutrition and family limitation. It is only after adequate laboratory and field research into the multifarious problems of absorption, interaction and utilization of various food fractions and accessory food factors that the agriculturist, pisciculturist and stock farmer can set about providing the recommended cheap sources of protein and protective foods. To Robert McCarrison we must pay tribute because, although not a trained scientist, he early realized and insisted on the supreme importance of research into well-balanced and protective diets, and on the provision of nutritional research institutes on the lines of his pioneering laboratories in Coonoor. With the teeming multitudes increasing with explosive force and living longer on account of our ministrations, there is much truth in the aphorism, an atomic bomb is not so dangerous as the Anatomic Womb; and the need for wide-spread instruction in cheap and safe contraceptive methods is almost paramount in its urgency. Tubo-ligation and vaso-ligation have become popular among well-to-do classes in India and Burma, but that does not touch the fringe of the problem. It is surprising how little the average doctor coming from the tropics knows about this problem. The Colombo Plan authorities have provided much help through the medium of the Family Planning Association. In the West African Medical Journal there appeared last year a remarkable article by Dr. G. M. Bull, Professor of Medicine at Belfast. After a tour of Nigeria, made at the invitation of the Nigerian Government, he published his recommendations. From any
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medical man they would be remarkable. Coming from a whole-time bedside teacher of medicine they are surprising. His thesis is arresting and deliberately provocative-It is that the National income of Nigeria cannot support a standard of hygiene and medical care equal to that obtaining in Britain ; that the first priority is to increase national income; that communications, agriculture and education are the items of outstanding importance; and that anything spent on health should, if possible, have the additional aim of improving national income. He points out that the increased expectation of life in Britain is due to public health measures, good water supplies, improvement in diets, housing and drainage, and that public health schemes are cheaper in the long run and infinitely more effective than curative medicine. He recommends that for many years to come expenditure on health should be kept at a minimum lest it delay other more important developments, and that at the present time curative medicine is a luxury which at present must be dispensed very sparingly. At the present time in Nigeria six times more is spent on curative than on preventive medicine. Bull recommends that preventive medicine should receive at least two-thirds of money available for health schemes. These are harsh words and grim, but is there not much truth in them? A compounder or dresser with a few shillings worth of chloroquine and sulpha pills can render more valuable relief than a member of the Royal College of Physicians with thousands of pounds worth of electronic equipment ; and his vaccination lancet and inoculation syringe would do so much more good in preventing suffering. For vote getting and other political reasons a large hospital with marble halls has a stronger appeal than a piped water s u p p l y - and, incidentally, I often wonder if those purveyors of marble halls are aware of the sterling work performed during the past hundred years or more at places like Calicut, the spot at which Vasco da Gama first landed in India, where the district hospital consisted of little more than wattle walls and a roof of local tiles - - b u t within those walls fine advanced surgery was carried o u t ; indeed, within them Fraser worked out his technique for ureter-implantation in the bowel which has put an end to so much suffering from vesico-vaginal fistula. Do gigantic modern hospitals really have a high priority ? Does such an imposing structure as Ibadan hospital with its huge drain on national finances really justify itself ? Does anyone who has visited the sheds at Shikarpur where our outstanding missionary surgeon, Sir Henry Holland, performed such prodigious feats of ophthalmic surgery, doubt that a man with a will is still what matters most ? Expensive equipment can be dispensed with as a high priority in backward countries. In contrast to Professor Bull's thesis we have the recommendation of another British professor of medicine who urged the supply to hospitals in South-East Asia of numbers of Melrose Heart-Lung pumps to boost British prestige, and to relieve the effects of congenital heart disease. The Colombo Plan authorities took the trouble to send a team of experts from Hammersmith to visit a capital in South-East Asia and to estimate the expenditure necessary to train and equip one specialist team for modern cardiac surgery. The estimate was £40,000. We are really in a terrible dilemma. Money is limited. Are we to cure or alleviate relatively rare conditions requiring expensive apparatus, or to use our money for the prevention and alleviation of mass suffering ?
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It is most important that Ministers of Health should be well-educated men with a knowledge of science and with balanced judicial minds and that their technical advisers - the Directors of Health Services - - should be men with leanings to the preventive side, but with an all-round knowledge of medicine. In India we made one gigantic mistake which I am glad to say the present Government of India has rectified. In the Central Government and in the provinces therapeutic medicine and hospital administration were dealt with separately from the preventive and hygiene side. The Director-General and the Public Health Commissioner dealt separately with their subjects, the Inspectors General of Hospitals and the Directors of Public Health were heads of their own departments and gave individual and often differing advice to their Ministers. But the Hospital men had the higher rank, and it was a matter of promotion for a Director of Public Health to become a hospital inspector. This was obviously wrong and should never be repeated. In South-East Asia the White Elephant is a sacred object. The gift of it by a prince to a subject was more often than not an acute embarrassment to him, as it ate him out of house and home and required constant care from a host of attendants. Let us not embarras the new countries with gifts of White Elephants in the shape of gigantic hospitals, coloured television apparatus, electron microscopes and other advanced specialized equipment. Sir Andrew Balfour who did so much for tropical medicine used to refer to the benefit of a touch of snow on the mental powers. The highest grade of research work can be carried out only in cool invigorating climates : air-conditioning is not an adequate substitute. Two kinds of research worker are needed. High-power workers in temperate climates and well-trained competent workers for prolonged periods in the tropics. These men must have security of tenure and long-term prospects of employment guaranteed by a stable government. The former type should, however, visit the tropical scene of operations at intervals so as to keep in touch with actuality. The day of the general scientific practitioner has gone. In its time it yielded wonderful results. I recollect my friend Henry S h o r t t - one of our former P r e s i d e n t s - when at the King Institute near Madras conducting simultaneously experiments on the malaria parasite, the virus of sandfly fever and dengue, on the fluorine content of water and its effect on skeletal structure, on the therapeutic value of a leishmania vaccine prepared from cultures obtained from the nasal mucosa, and on certain aspects of snake venom therapy. The I.M.S. officer like Habbakuk was said to be capable de tout, but during the past decade laboratory techniques have changed so greatly that the scientific g.p. is a back number. There is increasing room for international co-operation in the tropical field of research. We are all aware, I hope, of the story of Kyasanur Forest disease - - of the discovery of its cause and course and of the preparation of an effective vaccine within a matter of months of the first cases of a mysterious disease being reported from Mysore State - - International co-operation was then seen at its best. It would be appropriate here to draw your attention to the work being carried out in Madras during the past few years on the domiciliary treatment of tuberculosis. The findings have been startling and indeed revolutionary, for they tend to show that patients with pulmonary tuberculosis can be treated as effectively and safely in their homes as in h o s p i t a l - that specific drugs given once a day may be as effective as if administered three times a day with meals according to tradition, that patients can be treated without ceasing work, and that it is not so much the open case as the undetected case that is dangerous.
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There is an outstanding example of International Co-operation in R e s e a r c h - the participants being the Madras Government, the World ttealth Organization, the Indian Council of Medical Research and the Medical Research Council of Great Britain. The work is by no means complete but it is obvious that results of the highest importance for all countries of the world are emerging. For the success of such schemes good faith between subscribing bodies is essential and support promised at the beginning by a country or State must be given right through to the end. During our years in India, relations between British workers in the research and hygiene fields and those of the International Health Division of the Rockefeller Foundation were not only friendly but were cordial and complementary. The Rockefeller workers, like the British, had the security of continuous pensionable sen.ice. In the University of Rangoon where the two constituent colleges - - British and American (University College and Judson C o l l e g e ) - faced each other on the same c a m p u s - the mutual love and affection enjoined on us by William Harvey were much in evidence. The attitude of the American press has not always been friendly to us and American publishers have sought to give an anti-British slant in their books, but fortunately this has not affected relations between British and American field workers, and it is of supreme importance that scientific workers in the tropical field from both sides of the Atlantic should retain their bonds of esteem and friendship. My main thesis is that a high proportion of money available for aid in the health field from British sources should be spent on British-based research, and that most of the remainder should be directed into the field of health education. One often hears the question asked : " Why not leave all this to the World Health Organization " ? - - t h e most conspicuously successful part of United Nations activities. The World Health Organization has been a powerful factor for good in underdeveloped countries, its work in the fields of malaria and yaws control deserving special mention ; but as the late Secretary-General, Mr. Hammarskjold, reminded us, he was constantly being worried by demands for staff appointments to be made on a strict national-proportional-representation basis. This inevitably leads to diminished efficiency and to short-term contracts. We gladly pay our share of W t t O expenditure, but we owe it to our partners in the Commonwealth to provide dependable sustained long-term aid. There exists in this country among all peoples and all parties a general desire to help emerging independent countries. What can we do ? The first essential is tact, sympathy and a sense of proportion. Secondly : Britain must set a better example in the working of our National Health Service. It is a fine service, well conceived and it got off to a good start. It is being closely studied by overseas governments, both friendly and unfriendly, and must not be allowed gradually to drift, as it is doing, into a service which it is not quite proper for an educated or moderately well-off person to use if he or she can possibly scrape up the money or insurance premium to avoid doing so. Thirdly : we must ensure that the large army of young clinicians who come from abroad to get further training and experience here are not merely used as hands, but that the consultants under whom they work give up a substantial amount of their time to teaching
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and supervising them. There should be no such thing as a non-teaching hospital or a non-teaching consultant. A senior teacher from Britain who recently returned from a visit to India said he was shocked to find the number of clinical professors and lecturers in that country whose only contact with hospital work in Britain was in remote and obscure hospitals in minor industrial centres. Fourthly : we must make more provision for laboratory training for workers from the tropics. There is a great shortage of medical laboratory workers in Asia and A f r i c a - welltrained bacteriologists and virologists capable of running vaccine and serum-producing plant are at a premium, and training vacancies in this country are woefully insufficient. There are ample arrangements for diploma work in tropical medicine and hygiene and for the diplomas in public health and industrial hygiene ; but in morbid anatomy, clinical pathology and bacteriology the availability of diploma courses bears no relation to the demand. Many of us deplore the status given abroad to the diploma holder and the insistent demands by certain governments for training ending in the award of a parchment. Diplomas do serve in many areas as a guard against nepotism : the deplorable fact is that the laboratories of many undergratuate hospitals whose teachers have the benefits of the higher emoluments deriving from association with the National Health Service take no part in providing instruction in laboratory subjects at an advanced level for postgraduates from abroad. Some outlying provincial hospitals are giving commendable aid in this matter, and I must pay tribute to help given by the National Laboratory Service and its Director, Dr. G. S. Wilson. One of the principal ways in which our universities can help is by giving places for training to young doctors in the basic medical sciences of anatomy, physiology and biochemistry. There is a great shortage of teachers in these subjects and quite a number come here aiming at the Ph.D. It is better to put them through an honours B.Sc. course and to add a year at pure research at the end of it. I have seen some most gratifying results from t h i s - When a Ph.D. is insisted on, some universities make their syllabus elastic so as to enable the candidate to combine the honours B.Sc. syllabus with preparation of a Ph.D. thesis if a registrable medical degree is held. Sound training in the basic principles of science is one thing we can afford to give to overseas graduates, and is very necessary in order to combat superstition and traditional methods of the older generation in India and elsewhere. Fifthly : our medical schools must continue to allot a number of undergraduate places to Commonwealth students, especially to those countries which have not yet got facilities for such training. A recent survey showed that schools in Britain allotted from 4 to 9 per cent. of their undergraduate vacancies to such men and women. This may be considered to be a generous proportion in view of the number of wellqualified and keen young British applicants who are thereby excluded : but I must plead not only for a continuance of this facility, but for an increase in oversea intake even if it means opening up yet another medical school in Exeter, Plymouth or some such city. Finally : The Tropical Medicine Research Board must get real support. The two schools of tropical medicine in this country have done sterling work in the past by maintaining workers for prolonged periods overseas and by frequent short expeditions. The
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laboratories run by the M.R.C. in the Gambia and the institutions supported by interterritorial schemes in the colonial past have played an important part in advancing the state of medicine in the tropics up to the present time. The present influence of the Liverpool School which has resulted in notable foundations in Thailand and Ghana is very considerable, and Maegraith's dynamic energy is appreciated over a wide field. I am sure that after what may be a latent p e r i o d - long or s h o r t - the resources of our great institutions in this country will through the mediation of the Tropical Medicine Research Board play a full part in maintaining British influence in the future. I am not so sure of the advantages to be gained by the so-called " pastoral visits of consultants overseas to keep doctors in touch with new developments. It is sometimes forgotten that one can keep in touch by reading the literature. In the old days one could depend on having the top men available here all the year round except in August. It is becoming increasingly frequent for men from abroad to find on arrival here that the teachers at whose feet they have come to sit are in Honolulu, San Francisco or Sydney-especially from November to March. I can however vouch for the great benefit conferred by prolonged visits to overseas medical schools of teams of clinical teachers, such as that sent to India in 1955 by invitation under the Colombo Plan where the members worked in the wards and operation theatres for not less than three weeks in any particular institute and got down to basic teaching at the bedside. The Rosenheim mission is still talked of with bated breath in India. A repeat performance has been asked for and Pakistan wants parity. The recent teaching mission of Professor Last of the Royal College of Surgeons to Pakistan and Burma has been, it is reported, a revelation of what good teaching can be. In our relations with other countries we are sometimes embarrassed by requests which imply that our medical profession is not independent and that our learned colleges and institutions are subordinate to the Minister of Health. Our Government is from time to time asked to draft doctors from the National Health Service for work in newly independent territories. They have no power to do so. In treaty negotiations between Britain and foreign Governments it is not unusual for our Government to be asked to put pressure on the General Medical Council to recognize foreign degrees and diplomas. These Governments are astonished when they are informed that no such powers of compulsion exist. The independent medical profession is anxious and willing to give help, but requires guidance into the most appropriate fields. The new consultative committee chosen from leaders of the profession to advise the Minister for Technical Co-operation should, from its composition, be a guarantee to the profession that the best possible advice will be given. From my own experience of finding adventurous young men and women to go to such out-of-the-way and even dangerous fields as Laos, I am confident that doctors are still to be found here to venture forth to give a helping hand, if only employing bodies will give them some credit for their spirit and initiative on their return. I commenced this address with a reference to Sir James Cantlie, our founder. One of his main claims to fame is that he played a notable part in changing the course of the history of the world. Winston Churchill tells us that " it is always being changed by something" ; but the fact is that it was solely due to Cantlie's importunity and persistence that Lord Salisbury, "
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the British Prime Minister, was persuaded to secure the release of a Chinese political worker who had been kidnapped from the streets of London into the cellars of the Chinese Embassy, there to await transportation to China for execution. The victim was Sun Yat Sen, the founder of modern China. Years later, in 1923, as Professor Lancelot Forster has recently reminded us, Dr. Sun Yat Sen returned to the University of Hong Kong, and addressing the staff and students said : When I was studying in Hong Kong I compared my home in Heung Shan with Hong Kong, and though only fifty miles apart the difference in Government oppressed me very much. I began to wonder how it was that Englishmen could do such things as they had done with the barren rock of Hong Kong within 70 or 80 years while in 4,000 years China had no place like Hong Kong. You and I have studied in the English colony and in an English university, and we must learn by English examples. We must carry this English example to every part of China." "
Sun Yat Sen's call to his people to follow the English example will, we hope, continue to echo throughout the world so long as our country and our Society live up to the motto ZONAE TORRIDAE TUTAMEN.