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MEDICINE IN ZAMBIA
1031
Medical Education MEDICINE IN ZAMBIA MAURICE KING M.A., M.B. Cantab., M.R.C.P. PROFESSOR OF SOCIAL MEDICINE IN THE UNIVERSITY OF ZAMBIA
FOR a developing country Zambia is unusual. She is vast, flat, almost empty, subtropical country, landlocked in the middle of Africa. The transcontinental railway both dissects her geographically and divides her economically into the " line of rail " of prosperous towns and the endless identical vistas of sparse low forest-the potentially fertile Brachystegia woodland which is at once both her dominant ecology and her greatest natural challenge. In one corner, six huge mines smelt more than a sixth of the non-communist world’s copper, bring large amounts in foreign exchange, and rate Zambia high among developing countries on a per-caput income basis. The oldest living Zambians look back to the iron age, to the slow-moving autocracy of colonialism, and to eleven uneasy years in federal harness with Rhodesia. By Independence in 1964, only 109 Zambians had graduated, and only 1200 had obtained a school certificate, about the same number as Ghana had in 1943 or Tanzania in 1960. The country fared no better in medicine than she did in education. The ending of the colonial period turned the medical service in on itself. No new ideas could come in with cross-postings from other colonial territories, and with the coming of federation many good men took lump sums and left. Others did the same when federation ended, and there are now few doctors in the service over thirty-five. In medicine the federal record in Zambia was one of low service morale, a neglected auxiliary infrastructure, minimal training endeavour, the failure even to begin true health-centre services (compare with what Kenya did meanwhile), and the attempted provision of a chromium-plated service for the fortunate few. Independence had a profound effect. It came at a time of high copper prices, and meant that for the first time Zambia could use all her own revenues for her own development, and particularly for her own belated education. In the first years of independence the rate of secondary-school expansion was the highest ever attempted in any developing country. In 1966 ten times more classrooms were built than in any previous year. But education is only one urgent national need; a four-year development plan is being hurried forward, and on every side projects of many kinds are in hand. But all is not easy. Lack of education in previous years has left behind it a shortage of skills of every sort, from paediatricians to plasterers. Communications, which were never easy, are now further hampered by the division of the railway system between Zambia and Rhodesia, and Rhodesia’s unilateral declaration of independence. High prices and scarce materials are the result, so that Zambia’s wealth now buys less development than it might, and in the years to come the constraints on progress that are familiar elsewhere will be felt here also. Nevertheless, Zambia’s industry diversifies, and her gross national product increases rapidly.
a
THE UNIVERSITY
i
I
Zambia has high hopes for her university. Her people helped to pay for it by national subscription-and if a Zambian had no shillings he sometimes gave one of his chickens. It opened with great speed in temporary accommodation and enrolled more
than twice as many Zambians the year it opened in 1966, than had ever before graduated elsewhere. The Lockwood Committee,! who reported on the development of the university, required that it be responsive to the needs of the country and win the respect of the university world. It must combine, they said, practical service to the nation at this critical time in her life, with the fulfilment of the historic purpose of all universities, which is to be a seat of learning, a treasure house of knowledge, and a creative centre of research. These words have already been taken to heart and the staff are well aware that they live in no ivory tower. Zambia needs many graduates, so there are to be nearly 3000 students by 1971 and a maximum of 5000 by the mid-1970s. Students enrol at 0 level and reach first-degree status in four years. Above all, Zambia needs the professions, so there are, or soon will be, schools of science, ;medicine, education, engineering, agriculture, law, and administration. She has many able adults who have had no opportunity to acquire a university education, so the Zambian must be able to obtain his degree by correspondence. Members of the subprofessional cadres are in short supply, so there is provision for university diplomas in any necessary
technology.
Hitherto the required staff have usually been found, and recruiting standards have been rigorously maintained: some staff members for the school of medicine are to be recruited from the Soviet Union, among them will be the dean. English be the teaching language at the university. But is all this effort only to replace a white expatriate elite by a black Zambian one ? Will Zambia, like many other African countries, have a new tribe, the Wa-Benzi?(Unfortunately for British trade, the Mercedes-Benz has become a status symbol par excellence south of the Sahara.) Will a graduating student at a farewell dinner be able to say, in all seriousness, as one was heard to say elsewhere: " What have we got to thank our university for ? We have got to thank it for making us big men and able to earn E900 a year " ? It is not easy to educate a graduate who really is responsive to the needs of his country ", but a good start has been made. The very scale of the university will reduce elitism, as will the determination of the staff not to be an elite themselves-no high tables here.
is
to
"
,
THE SCHOOL OF MEDICINE
The acceptance on the day the university opened of 0-level students destined to become doctors imposed a fierce pace of development on the school of medicine. A World Health Organisation team was called in to advise, and their report2 is largely being followed. Preclinical instruction starts in 1968 and the first students will qualify in 1973. In a developing country a doctor’s main task must be to act as a teacher, organiser, supervisor, and consultant to a team of auxiliaries. Only when he and his helpers form a team will the best use be made of his very precious services. The medical student will therefore be trained for these roles-especially that of teacher. Such instruction is believed to be an innovation in medical curricula and will be part of the course in social medicine. This is not an easy subject to teach, and some means must be found whereby the student does not graduate with the feeling that, compared with clinical medicine, social medicine is " lousy, boring, and obvious "-an attitude of mind he is too often left with. It is commonplace that prevention must be integrated with cure. Perhaps the teaching of curative and preventive medicine has to be integrated too, and examined together " as medicine " ? But cure tends to swallow up prevention just as easily in a medical curriculum as it does in the on the Development of a University in Northern Rhodesia. Government Printer, Lusaka, 1963. 2. Jessop, W. J. E., Vine, J. M. The Establishment and Development o a Medical School within the University of Zambia. World Health Organisation, Geneva, 1966.
1.
Report
1032
T
Zambia’s
Brachystegia woodland:
a
challenge,
a health service. This means that the time allotted to social medicine has to be carefully staked out, and part of the grade a student is given must rest on the evaluation of carefully chosen field projects. Anatomy and physiology are to be combined as human biology, and incorporated with sociology and psychology to extend with varying emphasis right through the curriculum. The W.H.O. report2 required that the Zambian graduate be able to do surgery, and although the one-doctor hospital is an anachronism, even in Zambia, the doctor here will have considerable call on his surgical knowledge. Anatomy must not therefore suffer quite that devaluation to which it is at present being subjected in some schools elsewhere. Wherever possible it is to be hoped that the study of the normal and the abnormal will be integrated in " topic teaching ", but these good intentions are really only pious hopes, for they depend so much on the ability of particular teachers to work together. A course on infectious diseases will provide an admirable opportunity to integrate clinical medicine, preventive medicine, and microbiology. In common with other developing countries, Zambia’s population is growing rapidly (nearly 4 million at present), despite a high infant mortality from malnutrition and infections, particularly measles. Bilharziasis, ancylostomiasis, tuberculosis, leprosy, and poliomyelitis are all common, but smallpox has been virtually eradicated. On the roads, Zambia’s accident-rate is in some respects
budget of
Zambia’s
answer to
the
no
less to medicine than
to
other
---
._.__.
_
_.
disciplines.
among the worst in the world. expansion is now under way
Massive health-centre with training schemes for auxiliaries to man these new centres. They will be the spearhead of medicine in Zambia, so the student must know how to supervise them. Later, when the numbers of doctors increases, he will also be expected to man them. Plans have been made for a 1000-bed teaching hospital training 100 students a year to be built beside the present hospital near the centre of Lusaka, an arrangement which will allow existing accommodation to be used for other purposes once the new hospital is built. Meanwhile, a large district hospital is to be built in an outlying suburb to relieve congestion. Fortunately there is excellent temporary accommodation for the school of medicine in what was once the Oppenheimer College close to the central hospital. At present this houses the university, which is already moving to a new campus now being built three miles outside the town. Human biology will be taught on the university campus close to the other biological sciences and particularly biochemistry. This may promote the unity of biology only at the expense of the unity of medicine, but it will allow the student to live on the campus in the company of his fellows from other disciplines for three of the seven years of his training.
challenge:
together
THE ZAMBIAN DOCTOR
So
far., there has been little that is uniquely Zambian
the
new
University of Zambia.
I
B
1033
about these ideas. What is to be made of the planning opportunity of a really clean slate ? For what shall the school of medicine be known ? For better or worse, the school will be known inside Zambia for how well it teaches as judged by the kind of doctor it trains-the ordinary Zambian (who, after all, gave that chicken) is properly concerned about how well he is treated. Beyond Zambia the ultimate reputation of the school will depend on how Zambians write and do research, not on what a tiny band of expatriates do for the school meanwhile. This too depends on how Zambians are taught. Not unnaturally, therefore, the school will ultimately be known for its teaching, not perhaps the best recruiting slogan with academic values being what they are, but possibly one that even established schools may have to consider after the publication of the report of the Royal Commission on Medical Education ? But what kind of doctor do nearly 4 million Zambians need ? A doctor’s role is mainly determined by the size of his list, and even at the present high rate of population growth a school training a hundred doctors a year can expect to produce a potential doctor/population ratio of 1/5000 by 1985. This is twice the W.H.O. target for developing countries, more hopeful than any other country in sub-Saharan Africa, and much more than enough to fill all potential medical posts on the " line of rail ". But will the Zambian graduate be willing to live and work where he is needed in the Brachystegia woodland, or will he prefer to staff the British National Health Service ? Is it within the power of man to stop doctors moving from country to town and from poor countries to rich ones ? The pessimists " say: Forget the bush and develop the line of rail ". But the university has been commanded to be responsive to the needs of the country. It must therefore guide Zambia into making the utmost of this particular human ecological setting, which contains two-thirds of her people, almost all her land, and potentially much of her wealth. The school of medicine can only succeed in its role if the university, and through it the nation, sees this as its major challenge: the challenge and the answer are illustrated in the accompanying photographs. It is not sufficient, as the W.H.O. report suggested, merely to hope that some Zambian medical graduates might work permanently in the rural areas. It must be deep in the philosophy of the school that most of them must work there. How is it to be done ? Unfortunately there is no easy answer. Success will only be the result of multiple, wise, and radical decisions in many spheres of action over a long period of time. For better or worse some of these will be the high-level policy decisions of government; many will be politically difficult, perhaps even impossible; yet all are worth struggling for. Here are some of the many relevant factors in the medical field. The student must be given a precise statement of the aims of the school in his most impressionable moments when he first joins it. The Zambian doctor, like any other graduate, needs a general understanding of the way his country should develop, particularly what can be done in the rural areas. Provision is already made for this in a substantial course of African studies which all university students take in their second year. Wherever possible a student must be trained in a rural setting, and a " teaching district hospital " is already being considered. The student should also spend a few weeks with Zambia’s enterprising new flying-doctor service. Somehow there must be a rural differential in the salary structure-say, by a rural income-tax rebate or an urban income-tax surcharge. The traditional colonial pattern of restless postings must cease, and the rural practitioner must be encouraged to settle in one place, buy property, and even farm (there are excellent British precedents for this, and perhaps African doctors also have green fingers ?). Town doctors might be expected to find their own housing, whereas country doctors might have their housing subsidised. Rural practice must be made professionally attractive. This means that later on when there are enough doctors for health-centre practice to be more than merely
supervisory, the doctors working in them, who will be the true general practitioners of Zambia, must not lose touch with the district hospitals. The widely scattered population requires that these hospitals be as numerous and thus as small as efficiency allows. Even so they need good accommodation and equipment, and good laboratories and libraries, especially.
Many of
these decisions require a continued dialogue between the university and the Government, particularly the Ministry of Health. The relationship between them must therefore be close, firm, and above all charitable. The Ministry has a right to receive help in training auxiliaries if it is to give help in training doctors. In effect, the Zambian doctor must be designed round the medical service and the service round the doctor. This is but one example of the wider role the university has in designing the graduate for the needs of society, while at the same time strenuously endeavouring to lead society in the design of itself. It is one of the fascinations of the comparative microcosm of a new university in a new country that the individual can*feel himself playing some small part in this great task. In larger, older, and more complex communities elsewhere, he is more likely to feel himself powerless unless he achieves great eminence. It has been said that in well-established medical schools in Britain evolution is difficult and revolution, however urgent, impossible. In Lusaka the staff have an opportunity to learn from the old patterns of medical education, to invent new ones, and to design just the doctor Zambia needs. THE WORLD CRISIS IN MEDICAL EDUCATION
The creation of a new medical school is a bold venture at the best of times. To create one in Zambia now might even seem foolhardy, were it not so desperately needed, particularly since new schools in Dar-es-Salaam, Nairobi, Salisbury, Addis Ababa, Lagos, Zaria, Nsukka, and Accra are also competing for expatriate staff, not to mention more established ones like Makerere, Khartoum, and Ibadan. But this is only English-speaking Africa. Medical education attempts to expand throughout the world, with too few people, perhaps even nobody, to do the teaching. The whole corpus of medical knowledge expands prodigiously, and so does what it can do for the sufferer. But, on a world scale, the demand for medical care accelerates even faster, both in rich countries and in poor ones. Lack of doctors is the main bottleneck in providing it, but the bottleneck to the bottleneck is the lack of teachers of doctors. The history of medicine has shown different critical issues at different times-in the nineteenth century the need for wider application of the scientific method, more recently the need for better understanding of human fertility and the epidemiology of degenerative disease; not forgetting that present malady of British medicine whereby the equivalent of more than a quarter of her new graduates leave her shores each year (but not for Africa). Perhaps the most critical issue now is the need to increase the total number of the right kind of doctors in the world, with all that this means for the welfare of mankind. The individual doctor can only do what one brain and ten fingers will, but the teacher of doctors can, through his students, do much more. A medical teacher may claim to be the means of training one doctor every year, and so to multiply himself some thirty times before he dies. If a doctor is of particular ability, it is even more important that he teach, for his pupils will be abler too. It is the multiplier effect of all this teaching that world medicine needs so much, especially medicine in Zambia.
Medical Education MEDICINE IN ZAMBIA MAURICE KING M.A., M.B. Cantab., M.R.C.P. PROFESSOR OF SOCIAL MEDICINE IN THE UNIVERSITY OF ZAMBIA
FOR a developing country Zambia is unusual. She is vast, flat, almost empty, subtropical country, landlocked in the middle of Africa. The transcontinental railway both dissects her geographically and divides her economically into the " line of rail " of prosperous towns and the endless identical vistas of sparse low forest-the potentially fertile Brachystegia woodland which is at once both her dominant ecology and her greatest natural challenge. In one corner, six huge mines smelt more than a sixth of the non-communist world’s copper, bring large amounts in foreign exchange, and rate Zambia high among developing countries on a per-caput income basis. The oldest living Zambians look back to the iron age, to the slow-moving autocracy of colonialism, and to eleven uneasy years in federal harness with Rhodesia. By Independence in 1964, only 109 Zambians had graduated, and only 1200 had obtained a school certificate, about the same number as Ghana had in 1943 or Tanzania in 1960. The country fared no better in medicine than she did in education. The ending of the colonial period turned the medical service in on itself. No new ideas could come in with cross-postings from other colonial territories, and with the coming of federation many good men took lump sums and left. Others did the same when federation ended, and there are now few doctors in the service over thirty-five. In medicine the federal record in Zambia was one of low service morale, a neglected auxiliary infrastructure, minimal training endeavour, the failure even to begin true health-centre services (compare with what Kenya did meanwhile), and the attempted provision of a chromium-plated service for the fortunate few. Independence had a profound effect. It came at a time of high copper prices, and meant that for the first time Zambia could use all her own revenues for her own development, and particularly for her own belated education. In the first years of independence the rate of secondary-school expansion was the highest ever attempted in any developing country. In 1966 ten times more classrooms were built than in any previous year. But education is only one urgent national need; a four-year development plan is being hurried forward, and on every side projects of many kinds are in hand. But all is not easy. Lack of education in previous years has left behind it a shortage of skills of every sort, from paediatricians to plasterers. Communications, which were never easy, are now further hampered by the division of the railway system between Zambia and Rhodesia, and Rhodesia’s unilateral declaration of independence. High prices and scarce materials are the result, so that Zambia’s wealth now buys less development than it might, and in the years to come the constraints on progress that are familiar elsewhere will be felt here also. Nevertheless, Zambia’s industry diversifies, and her gross national product increases rapidly.
a
THE UNIVERSITY
i
I
Zambia has high hopes for her university. Her people helped to pay for it by national subscription-and if a Zambian had no shillings he sometimes gave one of his chickens. It opened with great speed in temporary accommodation and enrolled more
than twice as many Zambians the year it opened in 1966, than had ever before graduated elsewhere. The Lockwood Committee,! who reported on the development of the university, required that it be responsive to the needs of the country and win the respect of the university world. It must combine, they said, practical service to the nation at this critical time in her life, with the fulfilment of the historic purpose of all universities, which is to be a seat of learning, a treasure house of knowledge, and a creative centre of research. These words have already been taken to heart and the staff are well aware that they live in no ivory tower. Zambia needs many graduates, so there are to be nearly 3000 students by 1971 and a maximum of 5000 by the mid-1970s. Students enrol at 0 level and reach first-degree status in four years. Above all, Zambia needs the professions, so there are, or soon will be, schools of science, ;medicine, education, engineering, agriculture, law, and administration. She has many able adults who have had no opportunity to acquire a university education, so the Zambian must be able to obtain his degree by correspondence. Members of the subprofessional cadres are in short supply, so there is provision for university diplomas in any necessary
technology.
Hitherto the required staff have usually been found, and recruiting standards have been rigorously maintained: some staff members for the school of medicine are to be recruited from the Soviet Union, among them will be the dean. English be the teaching language at the university. But is all this effort only to replace a white expatriate elite by a black Zambian one ? Will Zambia, like many other African countries, have a new tribe, the Wa-Benzi?(Unfortunately for British trade, the Mercedes-Benz has become a status symbol par excellence south of the Sahara.) Will a graduating student at a farewell dinner be able to say, in all seriousness, as one was heard to say elsewhere: " What have we got to thank our university for ? We have got to thank it for making us big men and able to earn E900 a year " ? It is not easy to educate a graduate who really is responsive to the needs of his country ", but a good start has been made. The very scale of the university will reduce elitism, as will the determination of the staff not to be an elite themselves-no high tables here.
is
to
"
,
THE SCHOOL OF MEDICINE
The acceptance on the day the university opened of 0-level students destined to become doctors imposed a fierce pace of development on the school of medicine. A World Health Organisation team was called in to advise, and their report2 is largely being followed. Preclinical instruction starts in 1968 and the first students will qualify in 1973. In a developing country a doctor’s main task must be to act as a teacher, organiser, supervisor, and consultant to a team of auxiliaries. Only when he and his helpers form a team will the best use be made of his very precious services. The medical student will therefore be trained for these roles-especially that of teacher. Such instruction is believed to be an innovation in medical curricula and will be part of the course in social medicine. This is not an easy subject to teach, and some means must be found whereby the student does not graduate with the feeling that, compared with clinical medicine, social medicine is " lousy, boring, and obvious "-an attitude of mind he is too often left with. It is commonplace that prevention must be integrated with cure. Perhaps the teaching of curative and preventive medicine has to be integrated too, and examined together " as medicine " ? But cure tends to swallow up prevention just as easily in a medical curriculum as it does in the on the Development of a University in Northern Rhodesia. Government Printer, Lusaka, 1963. 2. Jessop, W. J. E., Vine, J. M. The Establishment and Development o a Medical School within the University of Zambia. World Health Organisation, Geneva, 1966.
1.
Report
1032
T
Zambia’s
Brachystegia woodland:
a
challenge,
a health service. This means that the time allotted to social medicine has to be carefully staked out, and part of the grade a student is given must rest on the evaluation of carefully chosen field projects. Anatomy and physiology are to be combined as human biology, and incorporated with sociology and psychology to extend with varying emphasis right through the curriculum. The W.H.O. report2 required that the Zambian graduate be able to do surgery, and although the one-doctor hospital is an anachronism, even in Zambia, the doctor here will have considerable call on his surgical knowledge. Anatomy must not therefore suffer quite that devaluation to which it is at present being subjected in some schools elsewhere. Wherever possible it is to be hoped that the study of the normal and the abnormal will be integrated in " topic teaching ", but these good intentions are really only pious hopes, for they depend so much on the ability of particular teachers to work together. A course on infectious diseases will provide an admirable opportunity to integrate clinical medicine, preventive medicine, and microbiology. In common with other developing countries, Zambia’s population is growing rapidly (nearly 4 million at present), despite a high infant mortality from malnutrition and infections, particularly measles. Bilharziasis, ancylostomiasis, tuberculosis, leprosy, and poliomyelitis are all common, but smallpox has been virtually eradicated. On the roads, Zambia’s accident-rate is in some respects
budget of
Zambia’s
answer to
the
no
less to medicine than
to
other
---
._.__.
_
_.
disciplines.
among the worst in the world. expansion is now under way
Massive health-centre with training schemes for auxiliaries to man these new centres. They will be the spearhead of medicine in Zambia, so the student must know how to supervise them. Later, when the numbers of doctors increases, he will also be expected to man them. Plans have been made for a 1000-bed teaching hospital training 100 students a year to be built beside the present hospital near the centre of Lusaka, an arrangement which will allow existing accommodation to be used for other purposes once the new hospital is built. Meanwhile, a large district hospital is to be built in an outlying suburb to relieve congestion. Fortunately there is excellent temporary accommodation for the school of medicine in what was once the Oppenheimer College close to the central hospital. At present this houses the university, which is already moving to a new campus now being built three miles outside the town. Human biology will be taught on the university campus close to the other biological sciences and particularly biochemistry. This may promote the unity of biology only at the expense of the unity of medicine, but it will allow the student to live on the campus in the company of his fellows from other disciplines for three of the seven years of his training.
challenge:
together
THE ZAMBIAN DOCTOR
So
far., there has been little that is uniquely Zambian
the
new
University of Zambia.
I
B
1033
about these ideas. What is to be made of the planning opportunity of a really clean slate ? For what shall the school of medicine be known ? For better or worse, the school will be known inside Zambia for how well it teaches as judged by the kind of doctor it trains-the ordinary Zambian (who, after all, gave that chicken) is properly concerned about how well he is treated. Beyond Zambia the ultimate reputation of the school will depend on how Zambians write and do research, not on what a tiny band of expatriates do for the school meanwhile. This too depends on how Zambians are taught. Not unnaturally, therefore, the school will ultimately be known for its teaching, not perhaps the best recruiting slogan with academic values being what they are, but possibly one that even established schools may have to consider after the publication of the report of the Royal Commission on Medical Education ? But what kind of doctor do nearly 4 million Zambians need ? A doctor’s role is mainly determined by the size of his list, and even at the present high rate of population growth a school training a hundred doctors a year can expect to produce a potential doctor/population ratio of 1/5000 by 1985. This is twice the W.H.O. target for developing countries, more hopeful than any other country in sub-Saharan Africa, and much more than enough to fill all potential medical posts on the " line of rail ". But will the Zambian graduate be willing to live and work where he is needed in the Brachystegia woodland, or will he prefer to staff the British National Health Service ? Is it within the power of man to stop doctors moving from country to town and from poor countries to rich ones ? The pessimists " say: Forget the bush and develop the line of rail ". But the university has been commanded to be responsive to the needs of the country. It must therefore guide Zambia into making the utmost of this particular human ecological setting, which contains two-thirds of her people, almost all her land, and potentially much of her wealth. The school of medicine can only succeed in its role if the university, and through it the nation, sees this as its major challenge: the challenge and the answer are illustrated in the accompanying photographs. It is not sufficient, as the W.H.O. report suggested, merely to hope that some Zambian medical graduates might work permanently in the rural areas. It must be deep in the philosophy of the school that most of them must work there. How is it to be done ? Unfortunately there is no easy answer. Success will only be the result of multiple, wise, and radical decisions in many spheres of action over a long period of time. For better or worse some of these will be the high-level policy decisions of government; many will be politically difficult, perhaps even impossible; yet all are worth struggling for. Here are some of the many relevant factors in the medical field. The student must be given a precise statement of the aims of the school in his most impressionable moments when he first joins it. The Zambian doctor, like any other graduate, needs a general understanding of the way his country should develop, particularly what can be done in the rural areas. Provision is already made for this in a substantial course of African studies which all university students take in their second year. Wherever possible a student must be trained in a rural setting, and a " teaching district hospital " is already being considered. The student should also spend a few weeks with Zambia’s enterprising new flying-doctor service. Somehow there must be a rural differential in the salary structure-say, by a rural income-tax rebate or an urban income-tax surcharge. The traditional colonial pattern of restless postings must cease, and the rural practitioner must be encouraged to settle in one place, buy property, and even farm (there are excellent British precedents for this, and perhaps African doctors also have green fingers ?). Town doctors might be expected to find their own housing, whereas country doctors might have their housing subsidised. Rural practice must be made professionally attractive. This means that later on when there are enough doctors for health-centre practice to be more than merely
supervisory, the doctors working in them, who will be the true general practitioners of Zambia, must not lose touch with the district hospitals. The widely scattered population requires that these hospitals be as numerous and thus as small as efficiency allows. Even so they need good accommodation and equipment, and good laboratories and libraries, especially.
Many of
these decisions require a continued dialogue between the university and the Government, particularly the Ministry of Health. The relationship between them must therefore be close, firm, and above all charitable. The Ministry has a right to receive help in training auxiliaries if it is to give help in training doctors. In effect, the Zambian doctor must be designed round the medical service and the service round the doctor. This is but one example of the wider role the university has in designing the graduate for the needs of society, while at the same time strenuously endeavouring to lead society in the design of itself. It is one of the fascinations of the comparative microcosm of a new university in a new country that the individual can*feel himself playing some small part in this great task. In larger, older, and more complex communities elsewhere, he is more likely to feel himself powerless unless he achieves great eminence. It has been said that in well-established medical schools in Britain evolution is difficult and revolution, however urgent, impossible. In Lusaka the staff have an opportunity to learn from the old patterns of medical education, to invent new ones, and to design just the doctor Zambia needs. THE WORLD CRISIS IN MEDICAL EDUCATION
The creation of a new medical school is a bold venture at the best of times. To create one in Zambia now might even seem foolhardy, were it not so desperately needed, particularly since new schools in Dar-es-Salaam, Nairobi, Salisbury, Addis Ababa, Lagos, Zaria, Nsukka, and Accra are also competing for expatriate staff, not to mention more established ones like Makerere, Khartoum, and Ibadan. But this is only English-speaking Africa. Medical education attempts to expand throughout the world, with too few people, perhaps even nobody, to do the teaching. The whole corpus of medical knowledge expands prodigiously, and so does what it can do for the sufferer. But, on a world scale, the demand for medical care accelerates even faster, both in rich countries and in poor ones. Lack of doctors is the main bottleneck in providing it, but the bottleneck to the bottleneck is the lack of teachers of doctors. The history of medicine has shown different critical issues at different times-in the nineteenth century the need for wider application of the scientific method, more recently the need for better understanding of human fertility and the epidemiology of degenerative disease; not forgetting that present malady of British medicine whereby the equivalent of more than a quarter of her new graduates leave her shores each year (but not for Africa). Perhaps the most critical issue now is the need to increase the total number of the right kind of doctors in the world, with all that this means for the welfare of mankind. The individual doctor can only do what one brain and ten fingers will, but the teacher of doctors can, through his students, do much more. A medical teacher may claim to be the means of training one doctor every year, and so to multiply himself some thirty times before he dies. If a doctor is of particular ability, it is even more important that he teach, for his pupils will be abler too. It is the multiplier effect of all this teaching that world medicine needs so much, especially medicine in Zambia.