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Of course, prevention is better than cure, especially from an economical objective; but how is this to be achieved? The present British government would like to know the answer to what has escalated into a political dilemma.
Preventive medicine had its origin(s) in the Royal Navy and Army; in the former James Lind (1716-94) and Gilbert Blane (1749-1834), and in the latter John Pringle (1707-82) were largely responsible for improvements. Preventive medicine in England thus ‘took off’ in the eighteenth century. It was an attractive idea to prevent disease in populations, rather than care for individuals.
During years in which I held several senior positions in clinical medicine in developing counties, a heated controversy arose concerning the correct balance involving prevention versus cure in those countries. The discussion, which was aired in local, national and international media, became, in the 1960s-80s, to a large extent polarised; should far more resources be put into primary care in rural areas, with relative neglect of tertiary care? In view of my position, I strongly backed preservation of the latter, recognising that a fine balance should ultimately be sought, and what is correct for one country is probably wrong for another. One of the most distinguished hospital administrators of the nineteenth century – Sir Henry Burdett (1847-1920) – certainly recognised not only a requirement for hospitals, but also the need for local ‘cottage’ hospitals close to the individual’s place of domicile.
Regrettably, this controversy became confused with the training of doctors and senior medical personnel, which many claimed should also be undertaken in rural areas. I believed this approach to be highly impractical, if not impossible.
After a decade, and more, working in Nigeria, Uganda, Zambia and Saudi Arabia, as well as in Papua New Guinea (PNG), I became increasingly convinced that a balanced viewpoint, i.e. between curative and preventive medicine, was both essential and the only way forward in both developing and developed countries. That is a simple ‘message’ and my underlying theme in this book.
The present British government, now the guardian of the sacred political cow initiated by Aneurin Bevan in 1946, is clearly backing a primary-care strategy, and is in danger of losing sight of the fine balance required between these two approaches. A recent editorial in the British Medical Journal for example, declared: ‘… With a shift in the UK towards practice-based commissioning the primary care view is set to prevail [in the NHS]’.5 Maybe the time has come, therefore, for a serious re-examination of a similar controversy which raged in the ‘third-world’ several decades ago. I maintained then that medical care required both components, and training of medical students and other medical personnel cannot be de-centralised, to anything like the extent many of the idealists were recommending. Excessive decentralisation is also presently being recommended in other professions also to a greater or lesser extent, but I suggest in this book that the situation in medicine in the ‘third-world’, exemplifies the controversy.
A good deal of this discussion centres on PNG because it was whilst I was there that much of the debate took place very largely in the wake of the explosion of writings on this subject in the 1960s and ’70s, which advocated massive changes in the direction of both training and ‘delivery of the goods’. PNG had, at the time of writing, enjoyed nearly a decade of independence from colonial rule, but possessed no adequate teaching hospital, and no indigenous medical practitioner trained to an international level of excellence in any medical specialism; such a situation, I considered, gave cause for grave concern.
This book is therefore in the main, an historical review based on literature of nearly half a century ago, regarding a correct balance in health-care resources for the ‘third-world’. I initially wrote the manuscript in PNG in 1980, but have updated it in 2007.
Many viewpoints in this book are my own and have been founded on my own experience of academic medicine in ’third-world’ universities. Most of the views expressed in Chapters 1 and 2 have their origin in idealist (Utopian) sentiments expressed by British doctors – most of upper middle-class background – as well as North Americans, working in newly independent African countries.
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Health Care For All: Preface
