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Traditional medicine in The Sudan
37 assignments were helpful and stimulating. They encouraged me to read up and keep abreast with my biochemistry (lectures). They made me remember what I learned.' Another one wrote 'Biochemistry is rousing my interest (in the nursing profession) because it is making clear why so many treatments are given and the underlying causes for the many diseases'. However, some interesting remarks made by the students supported my earlier views about our nurses, that is in most cases their errors of commission or omission were due to lack of understanding of the patients' condition or disease. The following are notable quotes: (a) 'The nursing profession has ceased to be the nursing of olden days where the nurse just carried out the Doctor's orders. Instead she should be able to provide intelligent care based on scientific theories and facts. Thus I feel knowledge of Biochemistry is essential to the nurse as well'. (b) 'When one knows the reason why one thing is done, she will do it properly, not mechanically'. (c) 'This is a worthwhile course and we need the knowledge in order to improve our nursing standards'. (d) 'It was an eye-opener'. These comments further reinforced the view that in order to improve medical care in this country, with the ever diminishing and over-stretched resources, it is necessary to improve the teaching standards in our health institutions. Appropriate teaching of some subjects, like Biochemistry, which are considered too complicated can thus make quite a difference in the way one uses his/her skills. This was better reflected by one of the students who wrote: 'I hope to use this knowledge to provide better care to patients and for planning appropriate nursing intervention'. Of course most of the things discussed in the course were known to them, but they had no idea as to what they meant. Thus, they could not intervene appropriately if the change in the patient's condition so demanded of them. Thus another student wrote: ' . . . the patient will also benefit because if all the nurses know why they are doing certain things then the patient is at an advantage'. It was clear from most of their essays that they felt the course is useful and that it would enable them practice their professions more knowledgeably than was the case previously. Among the suggestions made was that the course be expanded to include other topics such as renal, cardiovascular and gastrointestinal problems. It was also felt that the time was too limited, and that this needed to be increased so as to cover various additional topics and in more depth, the more so because the course was new to them and had introduced new words and concepts. It is now hoped that the course will include a few more topics and more time will be allocated. This should go some way towards fulf'diing the institutional objectives for setting up the Department of Post-Basic Nursing in the School of Medicine. The ultimate objective of the institution is to prepare nursing leaders capable of assuming positions in nursing administration, in nursing education, in public health nursing, in clinical nursing practice with emphasis on Primary Health Care, and to provide them with adequate resources, facilities and opportunities for their professional growth. Reference IAhmed M (1981) A new approach to teaching Biochemistry to Nursing StudentsBiochem Educ 9 19-20
B I O C H E M I C A L E D U C A T I O N 12(1) 1984
T r a d i t i o n a l Medicine i n T h e S u d a n BAKRI O SAEED* Introduction Sudan was originally inhabited by Hamitic-speaking people in the north and Negroid tribes in the south. Later the muslim Arabs infdtrated the country and were able to add an Arabic flavour to most of it. The southern part of the country remained isolated from the rest of the world until the turn of the eighteenth century. The ancient Sudan was the seat of the ancient Nubian civilization which co-existed and mixed with the ancient Egyptian civilization. Between the 7th and 15th centuries, the northern Sudan witnessed the rise and fall of three Christian Kingdoms. Arabization and Islamization of Bilad-al-Sudan occured over a long period of time by Arab infdtration through different routes. The rise of the Islamic Funj Kingdom in the 16th century accelerated the pace of Islamization of Bilad-al-Sudan. It encouraged Arab immigration which made the country a unique centre of cultural interaction which gave Islam the ascendency over Christianity and pagan beliefs. Fusion of the Pharonic, Christian and Islamic cultures with the indigenous cultures gave the Sudan a unique and huge cultural heritage of which traditional medicine is an integral part. Definitions Traditional medicine A group of experts from the African region, convened by the WHO regional office for Africa, met in Brazavllle and arrived at the following definitiont of traditional medicine:
" . . . the sum total of all the knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing". The present discussion will encompass three important facets. The African indigenous culture, the ancient Egyptian heritage and the Arab influence. In addition certain other selected topics will be described in more detail. African traditional medicine In the Southern Sudan, the development of traditional medicine has not been significantly affected by external influences. It is dominated by superstition and communication with spirits. The African traditional healer claims a sort of communication with spirits which reveal to him the aetiology and nature of disease and methods of treatment. A similar type of medicine predominates among the Nuba tribes in Western Sudan. There are many forms of treatment, including massaging or sucking the diseased part or taking preparations made o f herbs and animal parts.
* Dr Saeed is an MD from the Sudan who is at present doing research in the Department of Biochemistryof the Universityof Leeds. ~"WHO technical report series 622 (1978). The promotion and developmentof traditional medicine.
38 The traditional healer keeps his art very secret, and only when he becomes very old does he reveal his secrets to his eldest son. Thus, traditional healing tends to be the prerogative of certain families.
The Egyptian heritage The Egyptian influence is most marked in the northern Sudan which was originally inhabited by the Nubians. The Nile is an important deity in the ancient Egyptian culture. The ancient Egyptians used to throw a beautiful bride into the Nile every year as a sacrifice to the Nile God 'Hap'. The northern Sudanese throw into the Nile the placenta of the first child. The placentae of subsequent children are buried in the courtyard of the house after being carried at the head of a procession of laughing children. One of my patients in Khartoum civil hospital asked to be discharged from hospital so that she could deliver her baby at home. She was acting on her mother's advice that if she delivered in hospital the cats would eat the placenta and this might affect the future of the baby. People in the northern Sudan believe that the great river can confer a blessing. Thus new-born infants on their fortieth day, children after circumcision and newly-married couples go to or are taken to the river. Whatever the nature of the ceremony, it always involves contact with the water of the river. The Arab influence Sudanese culture, although dominated by Arabic and Muslim influences, has many distinctive features. The reason for this is that Islam entered the Sudan mainly carried by leaders of Suphisim. This being a less exact form of religion it incorporated many of the pre-existing pagan beliefs and practices. Many surgical procedures are carried out by the basir (skilled person). Blood-letting and blood-cupping are commonly practiced. Cautery is used to treat chronic illnesses, headache and jaundice. There are specific cautery positions for different illnesses. Even in Khartoum teaching hospitals jaundiced patients may be secretly removed by relatives during the night to be cauterized by the basir; they are returned to the ward before the morning and unless the doctor is sufficiently aware to notice the cautery marks it will not be noticed. The basir is particularly skilled in reducing fractures. The limb is splinted with palm leaves and left for the appropriate period. The basir also practices limb amputation, the stump being immersed in hot oil to stop bleeding. Al-shallag is specialized in ophthalmology. He treats cataract by removing the morbid lens in a simple operation. All forms of surgical treatment are carried out without any form of anaesthesia. The Sudanese noble is supposed to tolerate any surgical procedure, otherwise he will let down his family and his tribe.
Traditions and taboos of pregnancy, labour and children During pregnancy women take more starchy foods but in the last months they start eating raw liver. After birth the mother wears her bridal jewels, a copy of the Quran is kept near her bed so that the baby will not be touched by evil spirits. The mother stays in bed for forty days during which she is served by her relatives and neighbours. Labour is conducted by a B I O C H E M I C A L E D U C A T I O N 12(1) 1984
traditional birth attendant called 'the rope midwife'. During labour the woman assumes squatting position. A rope is tied to the ceiling and the woman holds on to it while the midwife sits between her legs to receive the baby. Many traditional birth attendants have been trained by the Ministry of Health to improve their practice and avoid complications. Being illiterate, they have to depend on colour and smell to identify the antiseptics and disinfectants they have to use. Use of herbs and medicinal plants Knowledge of the use of herbs and medicinal plants is accumulated over generations by a method of trial and error. Preparations are either used alone or as adjuvants to religious and magical treatment. Many herbs were found to be of clinical value, and their active ingredients have been extracted and tested for efficacy and toxicity. Herbalists believe that it is better to take the whole preparation than to take the purified active ingredient. They believe that the other constituents of a herbal preparation are useful in potentiating the actions of the active ingredients and/or nullifying the side effects. The rationale behind this is that man is part of nature, that there has been long interaction between man and products of nature and that human physiology is supposed to be conditioned to them. Examples include: Sunt pods used for many conditions, particularly fever and common colds. These are found to contain tannic acid which has an anti-pyretic effect. They are made as a decotion to drink, a paste rubbed over the diseased part, or eye-drops for certain eye problems. Karkacle (Hibiscus sabadariffa flower) is taken as a drink for coughs. Senna leaves boiled in water make a very strong purgative. Jardiga, a type of alkaline soil, is used to cure heartburn and stomach troubles. Female circumcision The origin of this custom is not definitely known. In the Sudan it is practiced widely in the North but is unknown to the negroes of the South. Two types are known: a minor one called sunna circumcision and a major type called pharoanic circumcision the name implying that it has come from pharoanic Egypt. Various reasons are given for the practice but generally it is done routinely as a way of conforming with the society and living in harmony with it. Many complications arise as a result of the operation which is often performed under septic conditions. Resulting infection may lead to sterility. Circumcision also affects the sexual life of the girl, interferes with labour and can cause serious complications. Mental disorders are reported due to this practice. They include forms of neurosis and psychosomatic disorders.* The custom is prohibited by law and publicly eriticised by religious leaders. In spite of this, different forms of female circumcision are still widely practiced in the Sudan.
Why study traditional medicine? (1) Traditional medicine is an integral part of each culture. Its * WHO/EMRO technical publication No 2. Traditional practices affecting the health of women and children, Female circumcision, childhood, marriage, nutritional taboos etc. Report of a seminar.Khartoum 10-15, February 1979.
39 study reveals many cultural characteristics of the community. (2) Traditional medicine has a hollstic approach, ie that of viewing man in his totality within a wide ecological spectrum, and of emphasizing the viewpoint that ill health or disease is brought about by a dis-equilibrium of man in his total ecological system and not only by the causative agent and pathogenic evolution. (3) Integration of traditional medicine and modem medicine can ensure total coverage of the whole country with basic medical services, which is not feasible in developing countries by relying only on the western type of medicine due to economic difficulties and shortage of manpower. According to Elsafi 75-85% of the entire population in Africa rely almost entirely on traditional medicine. Study and evaluation of traditional medicine is a pre-requisite for integration. (4) Being part of the people's culture it is particularly effective in solving certain cultural health problems. (5) Some harmful practices proved to be resistant to elimination by law, ie female circumcision in the Sudan. They are closely connected to the social systems and values and popular habits and beliefs. Analysis of these harmful traditions in the community perspective allows the experts to combat them more effectively. Acknowledgement I would like to express my thanks to Dr A Elsafi (President, Traditional Medicine Institute, Khartoum) for his encouragement and for making references available. I am indebted to Dr T A Scott for reading the manuscript and making helpful suggestions. An Australian's Impression of Biochemistry Educ a t i o n in N o r t h A m e r i c a n M e d i c a l S c h o o l s PATRICIA L G SHAW
Department of Biochemistry Monash University, Melbourne, Australia The problem of making medical students take biochemistry seriously is a difficult one, familiar to readers of Biochemical Education. There can be little doubt of the importance of biochemistry to medicine, as an inspection of virtually any recent issue of New England Journal of Medicine will confirm. But how do we convince our students that biochemistry is not just relevant but important to understanding disease, that increasingly biochemical information will be applied to the clinical problem-solving process, and that they ignore biochemical information at their patients' peril, when their respected rolemodels seem to get by knowing so little biochemistry? Our course at Monash University is not very different from that of most medical schools. We have the usual problems of biochemistry teachers with medical students: the latter apply themselves dutifully, with no great enthusiasm, to the shortterm ingestion and regurgitation of biochemical information. Little is digested and absorbed into long-term storage. 1 We have the usual separation of pre-elinieal from clinical training, so that by the time students are given the opportunity to apply basic science knowledge to clinical problems much of this knowledge cannot be retrieved when required.
BIOCHEMICAL EDUCATION 12(1 ) 1984
It was with the hope of gaining some educational insights which could be translated into useful action back home that I visited several North American medical schools in 1980. I chose to study the teaching process rather than content, as there seems to be general agreement about what should be included in a biochemistry course for medical students, but considerable divergence of opinion on how it should be taught. The schools visited were chosen on the basis of recommendations, or publications in the various journals of medical or biochemical education, and generally were those schools which to varying degrees had adopted innovative teaching methods. To anybody who would undertake a similar tour, I would recommend talking to students as well as staff. Most places I visited were only too happy to let me wander around and meet their students; but those schools with a highly organised visitors' schedule which seems designed to prevent this leave the visitor with a somewhat unsatisfactory, one-sided and incomplete impression of what really goes on and how successful it is. Space does not permit a complete survey of every school visited, only some general impressions with some higldights. At the time of my visit, there were some extremely interesting teaching methods being used. Probably the course with the most fundamentally different philosophical approach was that introduced by Dr Alan Mehier, at Wisconsin, described in a previous issue of Biochemical Education. 2 I attended a group session conducting an in-depth analysis of a paper selected from the literature, one which I personally found quite difficult. Dr Mehler put in an occasional clarifying word, but otherwise the detailed preparation and discussion was carried out entirely by the students, at an impressively high level. I would Like to think that any doctor attending me would bring to bear on my problem the same skills of thoughtful, probing and critical analysis and synthesis as were demonstrated by these students. The course placed a high priority on independent learning and problem-solving. Def'mition and transfer of factual information was not the primary objective, which made life rather more difficult for those students with no previous training in biochemistry. I was continually impressed with the great emphasis placed on independent learning. In many schools this was aided by well-constructed learning units, presented in written form, or as tape-slides, video tapes or computerised programmes. Some schools, such as Ohio State University, employed a combination of these methods, with students selecting the track of their preference; and at the time of my visit the Keller Plan for teaching biochemistry was operating with success. In most schools audio-visual aids were available; some schools offered totally computerised programmes, and many staff were enthusiastic about their teaching potential. My impression was that in general the students did not share this enthusiasm, and still preferred face-to-face discussions with a helpful staff member rather than a VDU. The expensive A-V and computerised facilities tended to be under-used. No doubt they have a place in any educational programme, but close staff involvement still seems very necessary.
B I O C H E M I C A L E D U C A T I O N 12(1) 1984
T r a d i t i o n a l Medicine i n T h e S u d a n BAKRI O SAEED* Introduction Sudan was originally inhabited by Hamitic-speaking people in the north and Negroid tribes in the south. Later the muslim Arabs infdtrated the country and were able to add an Arabic flavour to most of it. The southern part of the country remained isolated from the rest of the world until the turn of the eighteenth century. The ancient Sudan was the seat of the ancient Nubian civilization which co-existed and mixed with the ancient Egyptian civilization. Between the 7th and 15th centuries, the northern Sudan witnessed the rise and fall of three Christian Kingdoms. Arabization and Islamization of Bilad-al-Sudan occured over a long period of time by Arab infdtration through different routes. The rise of the Islamic Funj Kingdom in the 16th century accelerated the pace of Islamization of Bilad-al-Sudan. It encouraged Arab immigration which made the country a unique centre of cultural interaction which gave Islam the ascendency over Christianity and pagan beliefs. Fusion of the Pharonic, Christian and Islamic cultures with the indigenous cultures gave the Sudan a unique and huge cultural heritage of which traditional medicine is an integral part. Definitions Traditional medicine A group of experts from the African region, convened by the WHO regional office for Africa, met in Brazavllle and arrived at the following definitiont of traditional medicine:
" . . . the sum total of all the knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing". The present discussion will encompass three important facets. The African indigenous culture, the ancient Egyptian heritage and the Arab influence. In addition certain other selected topics will be described in more detail. African traditional medicine In the Southern Sudan, the development of traditional medicine has not been significantly affected by external influences. It is dominated by superstition and communication with spirits. The African traditional healer claims a sort of communication with spirits which reveal to him the aetiology and nature of disease and methods of treatment. A similar type of medicine predominates among the Nuba tribes in Western Sudan. There are many forms of treatment, including massaging or sucking the diseased part or taking preparations made o f herbs and animal parts.
* Dr Saeed is an MD from the Sudan who is at present doing research in the Department of Biochemistryof the Universityof Leeds. ~"WHO technical report series 622 (1978). The promotion and developmentof traditional medicine.
38 The traditional healer keeps his art very secret, and only when he becomes very old does he reveal his secrets to his eldest son. Thus, traditional healing tends to be the prerogative of certain families.
The Egyptian heritage The Egyptian influence is most marked in the northern Sudan which was originally inhabited by the Nubians. The Nile is an important deity in the ancient Egyptian culture. The ancient Egyptians used to throw a beautiful bride into the Nile every year as a sacrifice to the Nile God 'Hap'. The northern Sudanese throw into the Nile the placenta of the first child. The placentae of subsequent children are buried in the courtyard of the house after being carried at the head of a procession of laughing children. One of my patients in Khartoum civil hospital asked to be discharged from hospital so that she could deliver her baby at home. She was acting on her mother's advice that if she delivered in hospital the cats would eat the placenta and this might affect the future of the baby. People in the northern Sudan believe that the great river can confer a blessing. Thus new-born infants on their fortieth day, children after circumcision and newly-married couples go to or are taken to the river. Whatever the nature of the ceremony, it always involves contact with the water of the river. The Arab influence Sudanese culture, although dominated by Arabic and Muslim influences, has many distinctive features. The reason for this is that Islam entered the Sudan mainly carried by leaders of Suphisim. This being a less exact form of religion it incorporated many of the pre-existing pagan beliefs and practices. Many surgical procedures are carried out by the basir (skilled person). Blood-letting and blood-cupping are commonly practiced. Cautery is used to treat chronic illnesses, headache and jaundice. There are specific cautery positions for different illnesses. Even in Khartoum teaching hospitals jaundiced patients may be secretly removed by relatives during the night to be cauterized by the basir; they are returned to the ward before the morning and unless the doctor is sufficiently aware to notice the cautery marks it will not be noticed. The basir is particularly skilled in reducing fractures. The limb is splinted with palm leaves and left for the appropriate period. The basir also practices limb amputation, the stump being immersed in hot oil to stop bleeding. Al-shallag is specialized in ophthalmology. He treats cataract by removing the morbid lens in a simple operation. All forms of surgical treatment are carried out without any form of anaesthesia. The Sudanese noble is supposed to tolerate any surgical procedure, otherwise he will let down his family and his tribe.
Traditions and taboos of pregnancy, labour and children During pregnancy women take more starchy foods but in the last months they start eating raw liver. After birth the mother wears her bridal jewels, a copy of the Quran is kept near her bed so that the baby will not be touched by evil spirits. The mother stays in bed for forty days during which she is served by her relatives and neighbours. Labour is conducted by a B I O C H E M I C A L E D U C A T I O N 12(1) 1984
traditional birth attendant called 'the rope midwife'. During labour the woman assumes squatting position. A rope is tied to the ceiling and the woman holds on to it while the midwife sits between her legs to receive the baby. Many traditional birth attendants have been trained by the Ministry of Health to improve their practice and avoid complications. Being illiterate, they have to depend on colour and smell to identify the antiseptics and disinfectants they have to use. Use of herbs and medicinal plants Knowledge of the use of herbs and medicinal plants is accumulated over generations by a method of trial and error. Preparations are either used alone or as adjuvants to religious and magical treatment. Many herbs were found to be of clinical value, and their active ingredients have been extracted and tested for efficacy and toxicity. Herbalists believe that it is better to take the whole preparation than to take the purified active ingredient. They believe that the other constituents of a herbal preparation are useful in potentiating the actions of the active ingredients and/or nullifying the side effects. The rationale behind this is that man is part of nature, that there has been long interaction between man and products of nature and that human physiology is supposed to be conditioned to them. Examples include: Sunt pods used for many conditions, particularly fever and common colds. These are found to contain tannic acid which has an anti-pyretic effect. They are made as a decotion to drink, a paste rubbed over the diseased part, or eye-drops for certain eye problems. Karkacle (Hibiscus sabadariffa flower) is taken as a drink for coughs. Senna leaves boiled in water make a very strong purgative. Jardiga, a type of alkaline soil, is used to cure heartburn and stomach troubles. Female circumcision The origin of this custom is not definitely known. In the Sudan it is practiced widely in the North but is unknown to the negroes of the South. Two types are known: a minor one called sunna circumcision and a major type called pharoanic circumcision the name implying that it has come from pharoanic Egypt. Various reasons are given for the practice but generally it is done routinely as a way of conforming with the society and living in harmony with it. Many complications arise as a result of the operation which is often performed under septic conditions. Resulting infection may lead to sterility. Circumcision also affects the sexual life of the girl, interferes with labour and can cause serious complications. Mental disorders are reported due to this practice. They include forms of neurosis and psychosomatic disorders.* The custom is prohibited by law and publicly eriticised by religious leaders. In spite of this, different forms of female circumcision are still widely practiced in the Sudan.
Why study traditional medicine? (1) Traditional medicine is an integral part of each culture. Its * WHO/EMRO technical publication No 2. Traditional practices affecting the health of women and children, Female circumcision, childhood, marriage, nutritional taboos etc. Report of a seminar.Khartoum 10-15, February 1979.
39 study reveals many cultural characteristics of the community. (2) Traditional medicine has a hollstic approach, ie that of viewing man in his totality within a wide ecological spectrum, and of emphasizing the viewpoint that ill health or disease is brought about by a dis-equilibrium of man in his total ecological system and not only by the causative agent and pathogenic evolution. (3) Integration of traditional medicine and modem medicine can ensure total coverage of the whole country with basic medical services, which is not feasible in developing countries by relying only on the western type of medicine due to economic difficulties and shortage of manpower. According to Elsafi 75-85% of the entire population in Africa rely almost entirely on traditional medicine. Study and evaluation of traditional medicine is a pre-requisite for integration. (4) Being part of the people's culture it is particularly effective in solving certain cultural health problems. (5) Some harmful practices proved to be resistant to elimination by law, ie female circumcision in the Sudan. They are closely connected to the social systems and values and popular habits and beliefs. Analysis of these harmful traditions in the community perspective allows the experts to combat them more effectively. Acknowledgement I would like to express my thanks to Dr A Elsafi (President, Traditional Medicine Institute, Khartoum) for his encouragement and for making references available. I am indebted to Dr T A Scott for reading the manuscript and making helpful suggestions. An Australian's Impression of Biochemistry Educ a t i o n in N o r t h A m e r i c a n M e d i c a l S c h o o l s PATRICIA L G SHAW
Department of Biochemistry Monash University, Melbourne, Australia The problem of making medical students take biochemistry seriously is a difficult one, familiar to readers of Biochemical Education. There can be little doubt of the importance of biochemistry to medicine, as an inspection of virtually any recent issue of New England Journal of Medicine will confirm. But how do we convince our students that biochemistry is not just relevant but important to understanding disease, that increasingly biochemical information will be applied to the clinical problem-solving process, and that they ignore biochemical information at their patients' peril, when their respected rolemodels seem to get by knowing so little biochemistry? Our course at Monash University is not very different from that of most medical schools. We have the usual problems of biochemistry teachers with medical students: the latter apply themselves dutifully, with no great enthusiasm, to the shortterm ingestion and regurgitation of biochemical information. Little is digested and absorbed into long-term storage. 1 We have the usual separation of pre-elinieal from clinical training, so that by the time students are given the opportunity to apply basic science knowledge to clinical problems much of this knowledge cannot be retrieved when required.
BIOCHEMICAL EDUCATION 12(1 ) 1984
It was with the hope of gaining some educational insights which could be translated into useful action back home that I visited several North American medical schools in 1980. I chose to study the teaching process rather than content, as there seems to be general agreement about what should be included in a biochemistry course for medical students, but considerable divergence of opinion on how it should be taught. The schools visited were chosen on the basis of recommendations, or publications in the various journals of medical or biochemical education, and generally were those schools which to varying degrees had adopted innovative teaching methods. To anybody who would undertake a similar tour, I would recommend talking to students as well as staff. Most places I visited were only too happy to let me wander around and meet their students; but those schools with a highly organised visitors' schedule which seems designed to prevent this leave the visitor with a somewhat unsatisfactory, one-sided and incomplete impression of what really goes on and how successful it is. Space does not permit a complete survey of every school visited, only some general impressions with some higldights. At the time of my visit, there were some extremely interesting teaching methods being used. Probably the course with the most fundamentally different philosophical approach was that introduced by Dr Alan Mehier, at Wisconsin, described in a previous issue of Biochemical Education. 2 I attended a group session conducting an in-depth analysis of a paper selected from the literature, one which I personally found quite difficult. Dr Mehler put in an occasional clarifying word, but otherwise the detailed preparation and discussion was carried out entirely by the students, at an impressively high level. I would Like to think that any doctor attending me would bring to bear on my problem the same skills of thoughtful, probing and critical analysis and synthesis as were demonstrated by these students. The course placed a high priority on independent learning and problem-solving. Def'mition and transfer of factual information was not the primary objective, which made life rather more difficult for those students with no previous training in biochemistry. I was continually impressed with the great emphasis placed on independent learning. In many schools this was aided by well-constructed learning units, presented in written form, or as tape-slides, video tapes or computerised programmes. Some schools, such as Ohio State University, employed a combination of these methods, with students selecting the track of their preference; and at the time of my visit the Keller Plan for teaching biochemistry was operating with success. In most schools audio-visual aids were available; some schools offered totally computerised programmes, and many staff were enthusiastic about their teaching potential. My impression was that in general the students did not share this enthusiasm, and still preferred face-to-face discussions with a helpful staff member rather than a VDU. The expensive A-V and computerised facilities tended to be under-used. No doubt they have a place in any educational programme, but close staff involvement still seems very necessary.