When to leave the training nest?

If you start school aged five; then spend 7 years in primary school; 5 years at high school; 6 years to get your undergraduate degree; another 6 years to get your postgrad degree – how much more training do you need before you venture overseas? The answer isn’t all that simple. Some leave for further study; some go to work in very supported environments. I knew that I was heading into a pretty primitive situation. At that time there were 42 Ethiopian doctors in the world. All had trained overseas and 28 had remained overseas. The population of the country was quoted as 30 million. Including the 14 Ethiopian doctors there were said to be 300 doctors in Ethiopia. A disproportionate number were in  three big cities, Addis Ababa, Asmara and Jimma,• whereas the rural population was said to be 95% of the population. There were very few specialists. There was no training school for doctors in the country at that time.

A small, but significant, percentage of the 300 doctors were missionaries. Our  mission organisation alone had 5 hospitals, two with no doctor much of the time, but run by nurses; that is they were basically clinics. Between the other three hospitals we had a stable base of five doctors plus occasional very much appreciated short term help.

The medical advisor to the government of the time called the missionary doctors to a meeting. His opening statement was that he was an atheist and that when he came to Ethiopia he had no time for missions. But he had found that, thinking medically, missionaries had 10% of the work force and did 90% of the work. He then went on to discuss his plans for the future.

Returning to the thought behind the title of this post – what are the main medical needs in an underdeveloped country? So how much training should you undertake. The medical problems there are in many ways different from those in the West.

To make a list of their major needs: –

• Paediatric – high mortality  up to five years old.
• Obstetric care – perinatal infant mortality, maternal mortality, vesico-vaginal fistulae, ruptured uteruses.
• Tropical diseases – malaria, leishmaniasis, leprosy, TB.
• Surgical – emergencies, trauma, bowel obstructions. All those conditions we see in the West except fewer cancers. Surgery needs anaesthesia.
• Medical – very little heart disease, and very little diabetes; many public health issues, many infections.

There were very few investigations possible. There weren’t referral clinics.

I don’t know that it was at that time part of my deciding to go with limited surgical experience, but, in retrospect, I’m glad that I went when I did . That is, that I didn’t stay long enough to become overly dependent on investigations. They weren’t available.

At any rate, inexperienced as I was, I went early. I did my first obstetric and gynaecology operations there. I did many other operations that I had never seen; using textbooks, reading up before and, even then, often with a book open on my old violin music stand in the operating room, with a worker turning pages as needed. Maybe I was a bit of a cowboy; maybe fool hardy; maybe too self confident. But even in retrospect I don’t think I had a choice, even if my only consolation is that I was, I hope, better than nobody. And thank God I wasn’t alone – a wife, a few nurses and some very committed national helpers. And I suspect God played a part.

*Eritrea was at that time part of Ethiopia.

Dominic Cartier