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THE FUTURE OF SURGERY IN EAST AFRICA
Beware the historian who attempts to dabble in prophecy! It is often said that we study history so that we may be guided in choosing our steps towards the future. The limitations of this guiding force have been recognized already by Heraclit, who said that one can only step into a river once because by the next time one has changed and the river will have changed as well. In trying, nevertheless, to envisage possible scenarios for the future of surgery in the region, I shall use Heraclit's metaphor of the river. The course of the river, the changes in its level, the falls, the rapids, the shallows, the floods, with other words the political, cultural, socio-economic developments that will take place in the region are unforeseeable. Eastern Africa may find peace and unity, may stabilize, prosper and become a truly civil society, or Eastern Africa may sequestrate, disintegrate, degrade, become further impoverished and a place even more miserable than now. Or, more likely, our region will muddle on in spurts of improvement punctuated by lapses of deterioration. Whichever course the river will take, however placid or treacherous the river will be, there will be surgeons who have to navigate it, whether huddled in a little boat paddling desperately between rapids and eddies or sprawled on the deck of a comfortable steamer. In either case the boat will need a competent coaxvain. I like to think that the coaxvain will be the Association of Surgeons of East Africa or perhaps a daughter, a College, although, I must confess, I still harbor reservations with regard to medieval structures and names if they are not original. In the last fifty years the boat was often near to founder. She has hit rocks, was swept away in currents and she ran onto sand banks. During the dark, starless nights, the coaxvain repeatedly had lost his bearings. Nevertheless now, after fifty years, the boat, decorated in the colors of the golden jubilee, proudly sails forth. The journey of this surgical boat upon the river of Eastern Africa is not primarily for pleasure. The boat was launched in the service of the people who live along the river. Hence the mere fact that the coaxvain kept the boat afloat on a hostile river is not necessarily an indication that the journey was a successful one. Let us leave Heraclit, the river, the boat and the jubilee coaxvain. Let us examine surgery in the region as it is today, for only if we understand the present, can we hope to make rational plans for the future. Let us look at demography first. Surgeons have grown in numbers faster than the populations of our seven countries. In the fifty years the population has quadrupled, the number of surgeons has increased by more than one order of magnitude. However, fifty years ago the bulk of surgery was performed by doctors, not surgeons. The proportion of doctors who are capable, willing and in the position to perform surgery has decreased and as surgeons have not migrated into the rural areas, much of the countryside did not benefit from the increase in the number of surgeons. Throughout Eastern Africa surgeons are clustered in towns. There are many reasons for this, chief among them the fact that surgery has become highly commercialized. Almost every surgeon lives from fees in a fee for service system and only the urban population can afford to pay these fees (or the necessary insurance cover) surgeons (and doctors of every specialty) cluster around their potential customers. At issue is the disastrous maldistribution of income. The governments allowed a situation to arise whereby as much as 50% of the gross national income is earned by less than 10% of the populations. This is the new upper class. Although feudal in make up, this class lives in the towns, mostly in the capitals, and its retinue includes the surgeons. Moreover, surgeons themselves do not only live from the upper crust of society, they aspire, and, to a large extent, have succeeded in belonging to that crust. This is not to say that all surgeons have completely commercialized their practices and exclusively reserve their services to those who can purchase the same at market prices. A proportion of surgeons divide their time between public and private patients. Some do so as a matter of conscience. Others retain their positions in the public sector because, whilst the rewards, in terms of salary, are negligible, other considerations, such as status, power, representation are important to them. The public-private mix is a very asymmetric phenomenon and hence, even in the towns, the poor have rarely access to an acceptable standard of surgery. Another reason for the maldistribution of surgeons is because of specialization within surgery. The misguided imitation of a western, metropolitan development - a mal development in itself - created a situation whereby the surgeon's interest, training, capability and aspirations are so sequestrated as to prevent their migration to the periphery: neither could they satisfy the requirements of district surgery, nor would they derive satisfaction in the self-sufficiency and inventiveness imposed by austere environments - nor could they, if they stayed within their chosen field, make a living out there. There are other reasons for the urbanization of surgery: family considerations such as the spouse's job and the schooling for the children and the acculturation of the children to urban life are important factors. The clustering of the most successful surgeons in the capitals could have been made use of in medical education and in surgical training. This opportunity has not been seized. Surgeons in full time commercial practice do hardly contribute to teaching. Conversely, the best hospitals are not utilized for training and teaching. In consequence trainee surgeons are not exposed to state of the art surgery for even if their part-time public - private mix teachers are outstanding operators, the environments of the teaching hospitals are not conducive to learning of high standards. More disturbing is the fact that the best mission hospitals are not enrolled in medical education and training. Each of our countries has a handful of excellent mission hospitals. As far as the provision of medical care in the rural areas is concerned, these hospitals outpace the government institutions by many lengths. I was gratified to hear from Francis Omaswa that the Founders of the College of Surgeons of East Africa have recognized that the surgical training cannot remain tucked away in our present teaching hospitals. I spoke briefly about demography, accessibility and affordability of surgery. To complete the picture of the present, I have to enlarge on quality. The quality of surgery in the English speaking world used to be characterized by a high standard and a small standard deviation. Makerere and in its wake the other medical schools in Eastern Africa tried to subscribe to that ideal. Now surgery in our region is characterized by an enormous standard deviation in quality. The best surgery is of a very high standard, reflecting upon the talent of our peoples, the momentum of the outstanding past, Makerere in particular, the success of the various oversees training schemes, but also the relative sophistication of the clientele, commercial competition and the increasingly demanding regulatory role of the better private hospitals. On the other hand we see, again and again, performance of such low quality that we shudder. This applies to commercial as well as to government and also to missionary practice. In most of our countries we have, at this moment, dysfunctional governments and corrupt societies. Government cannot pay the surgeons, they cannot provide environments in which surgeons can work, they cannot supervise and by now, I am loath to say, they cannot any more differentiate between quality and pretense. When it comes to pretense, the universities, the medical schools, are in the forefront. An honest open reappraisal of their performance has not been attempted yet as most of our Ministries of Health and Education simply do not have the intellectual grasp and the political clout to ask the right questions. Hence, presently, in spite of some excellent work in selected places, surgery as a whole, training, practice, research and morality is deteriorating. Obviously there are differences between the seven countries in Eastern Africa, even within the countries. However in the last 10 years or so the similarities have become striking. Shall we now return to Heraclit's river and board the boat? The first scenario for the future to discuss is the one which would arise if we just let the boat drift in the current. Unregulated commercialization, continuing clustering in towns, further sequestration into sub specialties would create a system which will serve fewer and fewer clients and would and will eventually price itself out of business. The resulting down market move could be considered to be salutary, except down market quality control is even poorer. A far more salutary down market move would be achieved by the issuance and the implementation of a comprehensive fee system together with measures of better quality control. This is an inescapable step towards a better future. Surgeons are astute if not merciless critics of each other. This propensity can be modified and institutionalized in the form of expanded quality control. The Association has the know-how and the motivation to evolve a surgical quality control policy which could develop into an Inspectorate engaged on behalf of the Medical Councils. The medical profession, as a whole, must pursue the liberation of the Medical Councils from the Ministries of Health. In our present day world in the first place it is the government which needs supervision and regulation. Surgical training needs to be decentralized. Rotational programs must be developed according to which trainees spend time in the best private hospitals as well as in the best mission hospitals. At the same time the tendency to subspecialise must be reversed. This will be a slow and difficult process. The first step would be to follow the lead of Tanzania and demand that every surgeon - maybe with the sole exception of the ophthalmologist - must be a general surgeon first. The new college seems to think along these lines. The universities must allow the medical schools to expand their resource base. Private practitioners should be brought back into the mainstream, given honorary appointments, both to teach and to give service, partake in research. In the short span of their lives our universities have become entirely inbred. Indigenisation, whether on national or tribal level, is the surest way to destroy a university and is, in any case, a contradiction in adjecto, for what does the word "University" mean if barriers are erected? Regionalisation and internationalization of the medical schools would lift standards instantly. To make progress in these directions the coaxvain will need to have a firm hold on the rudder. So far he is still sailing in charted waters. Nothing what I have said so far is particularly new or revolutionary, and however uncomfortable some of the measures are deemed to be, to serve our people well far more inventiveness is required. The boat needs to be turned into the current and the coaxvain has to take control of every oarsman. The protectionist barriers have to be broken down. Common, everyday, urgent surgery ought not to be reserved to surgeons. Hence undergraduates must be again exposed to practical surgery, must carry a logbook, must have performed numbers of simple, frequently required operations. For such a revitalization to succeed, clinical classes must be smaller, medical schools have to decentralize. Such decentralization of clinical teaching is in everyone's interest and it will only be resisted by reactionary forces in the university, who's power, no doubt, will diminish thus. With the decentralization of the medical schools and surgical training, regionalisation and internationalization of medical schools, expansion of teaching, service and research, by inviting expertise from the private sector, independent Medical Councils aided by professional organizations, such as this Association, the scene is set for the creation of a regional body for the examination and accreditation of surgeons and of surgical departments. To some this may sound a very bold statement. The present M.Med programs came into existence in the first place because surgeons did not have a sufficiently well known and competent organization and because they did not trust the governments. The initiators of our local surgical training, who also happened to be founders and moving forces of the Association, settled on Makerere as the only authority that would carry enough clout to be recognized by the states. There is nothing in the Dekalogue nor in our laws that says that universities should decide who is a surgeon. The essence of a profession is that is regulates itself. Hence the Medical Councils or Boards decide who is a doctor. Those among you who think that in order to be recognized by the governments in these exalted roles, the Association needs to clone itself into a College - or beget a daughter by that name, perhaps you are right. After all these and some more measures have been taken, surgery in the region will have achieved a higher standard, a smaller standard deviation, will have become more affordable and accessible and will have regained some respect. Still surgery will remain too expensive and will remain out of reach of the poor. I believe that the simplest way to reduce the cost of surgery is to devolve surgery onto a new cadre of technicians. I do not suggest that we reintroduce a medical assistant cadre, cheap half trained surgical feldshers, let them lose on the poor and wash our hands. To the contrary, I believe that highly specialized routine diagnostic and operative techniques lend themselves to be carried out by technicians. The generalist needs the broadest training. Specialist technicians would benefit the rich and the poor. Not only would they be cheaper, potentially they would be better at their jobs within narrowly confined limits. Now we are rowing in a strong current, in foaming white waters. Fortunately some off the water ahead, above us, are reasonably charted, for we had come down this river once before in the current of restrictive practice, specialization, commercialization. On the other hand the river has changed channels, old forgotten arms are navigable again. The post modern word can learn from pre-modern times... The changes I foresee will be momentous. Skin grafters, TURpists, hernia repairers, cataract removers, coronary by-pass sutures, hip replacers.... do not we have them all already? We do, but the ones we have spent 35 years in school and training and expect to recover their school fees. Would industries welcome 40 years olds to work along an assembly line as novices? I have more unsettling suggestions. I believe that the fee for service system in its present form will vanish to be replaced by hospital based cooperatives. I do not for a moment think that managed care will be more than a passing phenomenon for both doctors and purchasers are already finding out that the managers who muscled their way in between doctors and patients came in for a cut and are not worth their cost. I believe that surgeons will become salaried people again. The better private hospitals will first act as fee collectors for the doctors and later ways will be found to convert the arrangement into a salary system. No lesser institution than the Mayo clinic has showed the way in that direction and has been a guiding light to many leading institutions in many parts of the world in this regard. Any large scale rearrangement presupposes that surgeons work in groups rather than as competing individuals. Presently partnerships and surgical group practices hardly exist in our countries, largely because we are so short of trust and are pathologically suspicious, sensitive and jealous. Yet we still have to contend with the poor. Nothing I have said so far will vouchsafe the access of the poor to high quality surgery. Mission hospitals alone will not be able to provide the service. It will take a long time before governments can and will pay salaries and provide working environments attracting high quality surgery to the periphery. I suggest a number of experiments. Private hospitals, located in the cities, should be encouraged to open clinics equipped with day surgery units in the economically depressed townships. Endowed beds should be made available in the private hospitals. These measures are not only a matter of charity, they will be necessary also to safeguard training environments. Much more expanded and more efficient flying doctors services could be made to organize comprehensive outreach programs. The basis of such programs would be commitment, personal as well as institutional, to assume responsibility for a given outlying hospital. Such responsibility would not only entail regular working and teaching visits but also the elementary form of telemedicine: communication per telephone and radio. Such partnership programs would also provide for pathology services, literature, x-ray review and the like. The fact that such a network does not already exist has less to do with the scarcity of funds than with the dearth of ideas, of organisatory capability and above all the lack of enthusiasm. What I have tried to describe here is far short of paradise. Many of the suggestions I made are stopgap solutions, improvisations, necessary while the slow process of moral, political, economic reconstruction of the region progresses. What most of the ideas I enumerated here have in common is that they could be initiated, put in place and managed by the profession, more precisely by the Association of Surgeons. I urge the Council to be bold, to think big and to think far ahead. It is written in Ecclesiastes: Without vision the people will perish. We surgeons, who are nearest to the immense sufferings of the people, ought to rise above the mediocrity so rampant around us and provide the vision. The genius of surgery in Eastern Africa, Sir Ian Mc Adam, in whose memory we have, in the gardens of Mulago Hospital, planted a tree - he had vision and he had enthusiasm. Also he sought and listened to advice. In formulating our thoughts we should continue to seek advice. We were fortunate in the past to have received so much guidance, so much institutional, personal and financial help from many surgical institutions, Associations and Colleges throughout the world, foremost from the Edinburgh College. We should continue with this special relationship, the purpose of which is not dependency, imitation and adulation but partnership. In the first fifty years the giant has often lead the dwarf by its hand. Now, to paraphrase Isaac Newton, it is time that the dwarf climbs onto the shoulder of the giant. Perched up there he will see far and will be able to warn the giant of what lays ahead, and who knows? The giant may, occasionally, listen. So, Pliny would be proven right again: "Ex Africa semper aliquid novi". 50th ASEA AGM and Scientific Conference Nairobi 1.12.99 Return to the History of Surgery in East Africa
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