Medical Education, 1977, 11, 221-230

COMMENT

Medical education in Thailand: an alternate perspective M . S. G O L D S T E I N

AND

P. J . D O N A L D S O N

School of Public Health, University of California, Los Angeles and The Population Council, Seoul, Korea

Summary

Recently two reports about medical education in Thailand have appeared in the literature (Buri et al., This research is an attempt to provide greater under1974;Dinning, 1974). Although the two articles are standing of two previously described medical about widely different aspects of medical education education programmes in Thailand by placing them they have a number of important themes and impliin historical perspective. One is a PhD programme cations in common. In this paper we shall specify to train medical school teachers and the other is a these themes and implications and try to set them community health programme for medical students. within a critical and historical perspective which, The underying assumptions of the programmes are though selective in itself, can provide a measure of specified and through the use of archival material it balance to the focus of the initial articles. is shown that in some respects the programmes are Each of the articles presents a brief discussion of quite similar to earlier efforts to create western the current state of health, illness and medical care medical education programmes in Thailand. The in Thailand, describes a particular facet of a medical analysis focuses on four major concerns of the proeducation programme with which the authors are grammes: creating small numbers of high quality associated, and finally suggests how these prodoctors versus greater numbers of less well trained grammes will have a beneficial effect on the state of personnel; distributing medical resources to unhealth and health care in Thailand. The description served rural areas; dealing with the special health of health and health care is not a bright one. needs of Thailand in the curricula; and self-conThailand is a nation of 38 million people, 85% of sciously creating a professional elite. The diswhom are in rural areas. The population is growing cussion points up the need for historical data in at a rate of 3.3% each year which makes it one of the evaluating the efficacy of medical education profastest growing nations in the world. Major medical grammes. problems and causes of death are gastroenteritis, Key words : EDUCATION, MEDICAL/*hiSt ; *DEVELOP- respiratory infections, TB, accidents, VD, malaria, trachoma and leprosy. Malnutrition is widespread, ING COUNTRIES ;HEALTH FACILITY PLANNING ;HEALTH especially among the young. 70% of the doctors are MANPOWER; SCHOOLS, MEDICAL/hiSt ; COMMUNITY in Bangkok, the capital, which has less than 10%of MEDICINE/edUC ; RURALHEALTH ; THAILAND the population. While the overall doctor/patient ratio is 1:7OOO, it is only 1:lOOO in Bangkok and Correspondence: Dr Michael S. Goldstein, School of Public Health, University of California, Los Angeles, CA less than 1 :lOo,OOO in the ‘truly rural areas’. Three 90024, U.S.A. medical schools produce about 250 doctors each Editor’s Comment: Readers may question whether the year, almost all of whom settle in urban areas after following account recognizes sufficiently the progress at the a brief period of national service in the Army or at Ramathibodi or Siriraj Schools. 22 1

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one of eighty-four government run hospitals in urban areas or one of 260 rural health centres. Only 200 of the 260 centres have doctors and most of the health districts (55 of 290) do not even have a health centre without doctors to staff it. Use of government outpatient services (rural and urban combined) is 0.2 visits per year, about a tenth of what is is in many African nations and a fifth of what it is in Latin America. Government expenditures for health care are $1.40 per person, per year, but only 20 cents per person, per year in the rural areas. Patient care is seen as work primarily for doctors and auxiliary personnel have been explicitly deemphasized, under-trained and under used by official agencies (Buri et al., 1974; Dinning, 1974). Two specific programmes are described to partially deal with the conditions described above. The first (Dinning, 1974) is a PhD programme in the life sciences at Mahidol University in Bangkok whose goal is to produce scientists to staff the pre-clinical departments of new medical schools the government plans to open. The programme is a collaborative effort of the Thai government and the Rockefeller Foundation (RF). Six new departments (anatomy, biochemistry, microbiology, pharmacology, physiology and pathobiology) were added to the already existing faculties of medicine, dentistry, and pharmacy. Now students have the option of going into either clinical or academic (MS and PhD) careers. Over a 12 year period (1964-76) the RF recruited foreign scholars to run the departments, until Thais who had been training abroad under R F support dould return and replace them. The foreign faculty has decreased from sixteen in 1970 to fewer than three, while the Thai faculty has risen from an initial zero in 1964 to over thirty. While the Dean has always been a Thai, the Associate dean was the R F representative in Thailand until 1972, when he was replaced by a Thai. All departmental chairman will be Thais by 1977. The authors report that applicant quality is high. Almost one hundred graduate degrees had been conferred by 1973, with many graduates going on to serve existing university faculties. By 1975, the medical teachers had published about 130 papers in scholarly journals, most in areas relevant to major Thai health problems. The programme is seen as a success in that it has produced graduates ‘able to participate in the international community of scientists’. The second programme (Buri et af., 1974) deals with the teaching of community health in the medical

school (Ramathibodi Faculty of Medicine) of Mahidol University. The programme’s main features are: (1) That it is interdepartmental. There is no separate department of community or preventive medicine which might allow the other clinical departments to feel that the topic was not their own responsibility. The director of the programme is the Chairman of the Department of Surgery. (2) The programme attempts to fully involve the School of Nursing as well as the Ministry of Health. Progress with the latter is vital but slow as ‘there is no precedent for close and sustained cooperation . . .’ (3) Much of the field work is done not in the University, but in a prototype rural district about an hour’s journey away. (4) The aim of the programme is to teach how a doctor and his assistants can provide health care for 50,000 rural people using limited resources. To do this the programme uses what it calls a ‘problem solving approach’ based upon ‘accepted principles of planning, management and systems analysis’. The actual programme consists of five courses, three which are required and two which are electives in the pre-clinical years. One elective is a 4 week summer course which conducts a health and demographic survey in a rural village. Of the 4 weeks only 2 are actually spent in the village, the remainder of the time is used for planning and data analysis. Many of the students have never been in a rural village before this time. The other elective is a 112 hour course on Analysis of Community Health Problems which aims to make students aware of what the major Thai health problems are and assign priorities to them; ‘encourage students to see health care delivery as a system’ and orient students toward planning and leadership roles within that system. The first required course is a 26 hour sequence in Community Health Planning, which appears to be a condensed version of the previously described elective course. During the senior year, a 6 week clerkship is required of all students. The clerkship is at the prototype rural district and its goals, in addition to fostering clinical skills, are to expose the students to the nature and seriousness of rural health problems as well as to design, administer and evaluate programmes in these areas. Time is divided between working in the clinic and carrying on a special group project selected by the students. The

Medical Education in Thailand final course is a required 1 month rotation in community health for all interns. Here the emphasis is on learning non-clinical responsibilities as planner, administrator, organizer and teacher. Special attention is given to the ‘leadership role’ of the doctor in a rural setting as well as learning the administrative structure and policies of the Ministry of Health. Although the architects of the community health programme cannot point to quantifiable results, as the life sciences programme does, their ‘ . . . clinical impression is that many students are indeed beginning to look at Thailand‘s health problems in new ways and feel a certain sense of personal responsibility for solving some of them’. Thus, by implication both programmes are seen as having a positive effect on the solution of the massive health problems described earlier. However, the information presented about these two programmes has other implications as well. Implications that are, perhaps, more important in that they go beyond descriptions of specific programmes in a single nation towards a generalized perspective for improving medical education and the delivery of health services in other developing nations. There seem to be three major tenets to this perspective. The first is a positive evaluation of the applicability and utility of a western model of medical education for developing nations. It is clear that the authors feel a heavy emphasis on the training of doctors is vital to the rural health needs of countries like Thailand. Furthermore, these doctors should be trained in a similar manner to those in America. Thus, a strong grounding in basic sciences offered by a faculty whose publishing record indicates participation in the ‘international community of scientists’ is a prerequisite for improving the health status of the Thai population. Training in community or preventive medicine is also presented in a very western manner. Strong emphasis is placed upon studying the community through surveys and developing administrative skills. A second major tenet which is implied here, and follows from the first, is a strong positive value on financial aid and technical assistance from industrialized western nations. If one is building a system of medical education based upon a western model it is logical to seek advice and support from the nations you are imitating. It is abundantly clear when reading about the programmes being reviewed here that while they are ‘collaborative,’ western experts have been the guiding forces. We should also note that in

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both cases the aid is not from a government but is private, from the Rockefeller Foundation which has long been a major source of funds and expertise for developing medical schools in developing nations. A third major tenet of these programmes is the importance of creating professionalization for development or modernization. The implicit assumption here is that these nations can only solve their problems (health care being just one example) through developing a highly trained group of professionals who not only have certain technical skills but who can take over leadership roles and decision making. Although never clearly articulated, this belief is omnipresent in these programmes. It is difficult to assess the validity of these assumptions. One reason for the difficulty in assessing the programmes is that they are described in a totally ‘ahistorical’ manner. It would be a great help if we could see these programmes in their historical context. By understanding how present institutions and programmes evolved through the past we may be able to relate or compare them to other alternatives that were, in the past, rejected in their favour. In other words, a full understanding and evaluation of today’s programmes must deal with what other options, if any, existed. If doing this provides some clues about current programmes, it may also provide some useful implications about the efficacy of today’s programmes for the future. In this particular case we must ask if it is indeed possible to look at medical education programmes in Thailand which: (1) utilized a western model, (2) were carried out and directed by foreign money and advisors from American charitable foundations, and (3) were based on increasing professionalization as a key aspect of development and modernization. In fact, ample precedents exist to justify a review of the historical origins and effects of these two programmes. The source of funds and expertise in the two programmes described above is the Rockefeller Foundation which, through its Division of Medical Education has long been involved with support for a wide range of research activities in medical education both at home and abroad (Nielsen, 1972). In Thailand (or Siam as it was called up to 1939) the Rockefeller Foundation is largely responsible for whatever system of, and facilities for, medical education existed at the time these two specific programmes were begun (Donaldson, 1976). Thus, it should be clear that in order to understand these

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programmes at all we must look at them in their historical context. It is our intention to specify a number of broad themes in the history of the RF’s medical education programmes in Thailand and relate these themes to the two current programmes described above. The bulk of our data is derived from sampling of materials at the Archives of the Rockefeller Foundation in New York City.* Based upon our examination of the material we have analytically distinguished four thematic concerns of the R F aid programmes, which while not mutually exclusive, merit deeper examination. These concerns are: (1) using R F funds for training small numbers of high quality doctors as opposed to larger numbers of less well-trained personnel, (2) given number 1, dealing with the maldistribution of doctors and other medical resources between rural and urban areas, (3) shaping the curriculum to deal with the real and special health needs of Thailand within the limits imposed by the other concerns of the RF, and (4) fostering the development of a modern professional elite. 1. Emphasis on doctors

Western medicine first came to Thailand through missionary doctors in the early nineteenth century

* There are many difficulties involved in relying heavily o n archival material. However, alternative sources of information are either non-existent, or in the case of much of the RF’s own published material, promotional in nature and thus of limited value. The major problem is one of sampling. Although a great deal of material was reviewed, much was not. For example, W. S. Carter is cited frequently. We examined Carter’s letters, reports, memos and the like which were filed under ‘Chulalongkorn University’, ‘Siriraj Hospital’, and ‘Siam’. However, we did not review Carter’s correspondence or reports o n other programmes or general foundation policy. This was typical of our approach. Secondly, we have used only items found in the archives. Some programme correspondence, including probably some of the most important material, was sent as personal mail to an individual’s home. Gregg writes of communication with Pearce which included ‘being able to write him at his home . . . about such items as did not belong in the record of the organization. Pearce warned me not to go too far with this privilege, but I can say it came in very handy’ (Gregg quoted in W. Penfield, The Difieult Art of Giving: The Epic of AIan Gregg. Little Brown, Boston, 1967). Ellis employed this privilege (Pearce to Ellis, 18 June 1924, RF617A). How often and with regard to what issues is not known. It is also important to note that there may have been conflicts within the R F itself. When he was Rockefeller Foundation President, Raymond Fosdick spoke of the ‘fundamental antipathies that often blazed into view’ (quoted in Penfield). We have found no evidence of conflict over the Thai programme but it may have existed. Unless otherwise cited, the material is from Record Group 1, Series 617A, Chulalongkorn University (RF617A).

(Ministry of Public Health, 1971). A medical school was opened at Siriraj in 1889 with forty students. Although it survived for over 30 years it was of extremely poor quality (McFarland, 1958). At the end of this period the Rockefeller Foundation had become very concerned with improving the level of medical education in terms of the criticisms levelled by the Flexner report. In the U.S.A., the R F took a subsidiary role to the General Education Board but abroad it took the lead in influencing medical education in Britain, France, Belgium, Canada, Latin America, the Middle East, South-east Asia, and the Antipodes (Nielsen, 1972). In Thailand, an R F official working on a hookworm project informed the Foundation on 3 August 1921 of Thai interest in improving medical education. ‘ . . . they were willing to let the R F have an American Dean . . . or if that was not enough they would let the Foundation have any amount of control they desired, if only the Foundation would come and help at this time’ (Barnes, 1921). With a Thai Prince co-ordinating the programme, a formal request for aid was made by the Thais on 10 August 1922 and agreed to by the R F on 9 December. Prior to this the R F Director of Medical Education, Dr Richard Pearce, had visited Thailand and written a report citing the need for two types of medical education: ‘A Class A school with proper entrance requirements . . . to supply a small number of well qualified Medical Practitioners who will act as leaders in important positions . . . ’ and ‘A practical school . . . with moderate entrance requirements, and giving two or three years training in the more elementary practical aspects of medicine . . . and thus supply as rapidly as possible the lo00 men above noted as necessary in the next ten years’ (Pearce, 1921). Although it was immediately evident to Pearce and others that the latter school was vital to the medical needs of the Thai people the R F only agreed to provide support for the small elite school. The Thai government would have to be the sole source of support for any others funds (Pearce, 1922). On 16 August 1922 the Thai Ministry of Education formally agreed to all the R F conditions of aid. Throughout the early history of the school the R F documents are filled with assertions to the Thais, as well as internal correspondence, attesting to the Foundation’s determination to support only the training of doctors despite the suggestions of the Thais or even their own advisors to the contrary (Carter, 1923; Heiser, 1925). The medical school of

Medical Education in Thailand

Siriraj was built and opened as planned. Between the opening of classes in 1924 and 1931 forty-eight graduates were produced: not enough to fill the already existing vacant government positions. The R F position in supporting only relatively few students of a Class A school remained vigorous. In fact, in 1929 A. G. Ellis, the R F representative and Dean of the school, sent a personal request to the Division of Medical Education to extend the aid on the grounds that if the R F pulled out the Thais would use the school to turn out larger numbers of less qualified men and/or paramedical personnel, who would be seen as doctors by the unsophisticated public (Ellis, 1929). Further appropriations were made expressly on the condition that training for a lower grade of practitioner not be considered by the school. Throughout the 1930s opposition to the school, based on its limited number of graduates, grew. Ellis launched a public relations campaign in Bangkok aimed at refuting this criticism. It included interviews, lectures, lobbying with local doctors and is typified by a pamphlet he published called ‘Medical Education and Practice’ (Ellis, 1932). While stressing the importance of not training ‘Jr. Doctors’, this pamphlet discussed a wide range of other topics and presented a plan for eventually building a network of hospitals and doctor directed rural health centres which is strikingly similar to the outline of rural health presented by Buri et al. (1974). By 1933, the R F was becoming somewhat more amenable to allowing the government to train paramedical workers for ‘humanitarian’ reasons if certain conditions were met. These conditions included: no R F funds to be used; a quid pro quo whereby the medical school would be relieved of pressu e to modify its policies; and a renaming of the position from ‘Jr. Doctor’ to ‘health assistant’ which would emphasize its subordination to doctors (Carter, 1933; Ellis, 1934). Educating a small number of doctors has remained a feature of medical education to the present day (Buri, 1970). In 1948 a second medical school was founded on the same premises as the first (Buri, 1970). The R F began to assist a new Thai medical school in 1963. By this time the medical needs of the Thai people has been well documented along with possible ways of responding to these needs by emphasizing the contribution of paramedical personnel. In 1965, an R F report entitled ‘Report to Thailand on Health Services, Health Personnel, and

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Health Education’ (The Rockefeller Foundation, 1965) called for stressing para-medical workers if Thai health problems were to be alleviated. ‘The present situation is that quantitative demands need to be met as well as the qualitative and this dual requirement can only be realized by delegating to a person other than a doctor responsibility for treatment of some of the more simple ills’ (The Rockefeller Foundation, 1965). The report suggested a variety of strategies for achieving this. One was a diploma course of ‘say two years’ to produce people who would work in rural areas doing a prescribed set of tasks. Another was ‘to graft on to the training of all para-medical groups employed at health centres and out-patient clinics, six months training in simple diagnostic and therapeutic procedures . . .’ (The Rockefeller Foundation, 1965). Another strategy was to ‘train a straightforward medical assistant who is concerned primarily with the sick individual . . . A course of between two and three years should prove adequate . . .’ (The Rockefeller Foundation, 1965). Thus it is surprising to find that the actual R F financial support has gone only to programmes which aim to train doctors such as the ones described in the opening sections of this paper. The life sciences programme aims to create a group of research oriented scientists who can teach relatively small numbers of medical students in their pre-clinical years, at regional medical schools which are not yet in existence. It is difficult to think of an expenditure of funds further removed from the training para-medical workers to meet the ‘quantitative demands’ of the country. The community health programme, while much less removed from delivering needed health services, also assumes both implicitly and explicitly that such services can only be delivered through a system based on and controlled by doctors. The need for para-medical workers to engage in delivering services and the refusal of doctors to work in rural areas and cooperate with public health officials are mentioned in the beginning of the paper (Buri et al., 1974). But the programme itself is oriented towards the training of doctors. 2. Distributing doctors and other health resources

The current Thai medical care system has often been criticized, not for the technical competence of its personnel, but for their distribution or lack of distribution throughout the nation (Ministry of Public Health, 1973; Bangkok Bank, 1973; Bryant,

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1969; Riley & Sermsri, 1974; World Bank, 1975). The present situation with most doctors practising in urban areas, especially Bangkok, and the rural areas remaining unserved is in large part attributable to the medical education system. Bryant notes that, ‘systems of health care are inseparably linked to the education of health personnel’ (Bryant, 1969). These educational systems have generally been copied from western nations (Bryant, 1969; Lathem, 1970). As the Bangkok Bank described it, ‘several factors militate against the growth of medical services in rural areas . . . the most important factor(s) is the nature of medical education in its present-day institutional form’ (Bangkok Bank, 1973). The key element in such medical education is the emphasis on training highly skilled doctors who because of their social origins, aspirations, and orientation toward high-technology, curative, hospital based medicine are not apt to practise in rural areas. Thus, the maldistribution of medical resources follows naturally from the emphasis on training only highlyskilled practitioners which we have described above. It was clear in 1923 when W. S. Carter visited Thailand for the R F that graduates of the planned medical school at Siriraj would not practise in rural areas, while men with a lower class of training as well as those who failed in medical school might be induced to practise there (Carter, 1923). In 1924, at the same time that the medical school was opening, M. E. Barnes, head of the RF’s Division of Medical Education wrote to the RF‘s International Health Board that a training school for rural health officers ‘must’ be established but that ‘It should not be connected at all with the medical school’ (Barnes, 1924). But as we have seen the R F did not support such a programme, either affiliated with the medical school or not. In fact it fought such programmes at every opportunity. In 1931, as the medical school was coming under attack for not supplying doctors to serve rural areas its director, Dr A. G. Ellis wrote to the president of the Thai Medical Council that there was no need for ‘Jr. Doctors’, health officers or medical assistants as ‘This crying need for doctors of the modern school is at present a theory rather than a fact.’ Rural people still needed to be ‘sold’ on modern medicine and thus there would be unemployment for ‘thousands of graduates of a modern school’ if it existed. Ellis suggested 60 or 80 years not 6 or 8 as the proper length of time for introducing modern hospital based

medicine to rural areas (Ellis, 1931). Although the need for some sort of rural practitioner became increasingly well documented little or no R F aid was forthcoming as this was seen as a threat to first-class medical education. The R F response, as summarized by Ellis in his Medical Education and Practice, was to call for putting all government resources into building a network of hospitals staffed by doctors throughout the country, one to a mondhol (province). After the hospitals were in place, health centres would fan out around them, only ‘if needed’ and act as ‘feeders’ to the hospital. Ellis stressed that public health programmes should only be attempted after this hospital system had been fully established (Ellis, 1932). An examination of the contemporary programmes described by Dinning and Buri et al. reveal that the RF response remains essentially the same today. Both programmes acknowledge the pressing need for increasing rural health services, which have barely changed since the 1920s. But both programmes serve to reinforce the dependence of the health system on highly trained doctors. The life sciences programme is spending vast quantities of money to train basic research scientists and teachers of preclinical subjects for non-existent medical students of non-existing medical schools. Next, the government will have to direct its funds to building new medical schools (surely in urban areas). The students who can gain admittance to these schools and graduate will themselves not be oriented to rural medicine, and their training will be in high technology, curative, hospital based medicine. The community health programme described by Buri et al., continues to assume that the solution to rural health problems lies with doctors. It takes for granted that most medical students are u aware Q of the nation’s major health problems and that they have little or no contact or initial interest in rural areas and their situation. The course work emphasizes survey research, systems analysis, and other topics which have the effect of increasing the social distance between the students and the rural inhabitants. Practical work during the clinical years and the internship is divided up into research, administration and hospital based medicine. A stated assumption of the programme is that if the graduates serve in rural areas it will be because they are forced to do so by government fiat (Buri et al., 1974). In many respects both of these programmes offer a facade of rhetoric oriented to the solution of rural health problems but

Medical Education in Thailand may well have the effect of increasing the disparity between urban and rural health resources. 3. Dealing with the health needs of Thailand After considering what sort of health workers will be trained, and where they will work, the most vital issue is what shall they be taught. Here we will focus on the question of how the health needs of Thailand were incorporated into the curricula of the medical schools. As early as November of 1921, R. M. Pearce, the Director of the Division of Medical Education for the RF, noted in his report on Thailand that ‘for many years to come’ public health and preventive medicine ‘would be the backbone of the medical profession in Siam’ (Pearce, 1921). However, Pearce was also clear that these topics were not to be emphasized by the medical school curriculum, but rather relegated to the ‘Class B school for health assistants or sanitarians. Thus when the Thai government signed the formal aid agreement on 25 October 1922 it was specified that public health courses were not to be part of the original curricula and that a formal school of public health could not be established ‘until the Medical School is properly recognized‘ (Prince Mahidol, 1922). Yet it was already clear that local pressure, as well as the International Health Board, would demand at least a solitary public health course for the medical students. Ellis soon agreed to this possibility as long as there would be no professor or department of public health. In that way public health would never have any competitive power in the medical school with other departments. Ellis was especiallyconcerned with what might happen after the RF turned the school over to the Thais. ‘ . . . the fewer the Siamese professors the fewer the chances of damaging differences of opinion as to the running of the school when we leave’ (Ellis, 1923). The International Health Board (IHB) continued to pressure Ellis and by 1926, 2 years after the school opened, there were plans to offer a practical public health course to the students. While the IHB complained to headquarters that it was improper for the Medical School faculty to determine how public health should be offered at the school, Ellis and the Division of Medical Education stood firm in allowing no public health professor (Barnes, 1926; Heiser, 1926; Carter, 1928a, b). Prince Sakol, the Director of Public Health in Thailand and President of the Medical Council, told

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the R F that curative and preventive medicine must go together and not be part of separate medical education systems (Carter, 1928a, b). Still Ellis continued to insist that preventive medicine be excluded from a significant place in both the medical school curriculum and the developing Thai medical care system. Rather, Ellis maintained, the Thais should stress surgery performed in hospitals as the fundamental aspect of medical education and practice. This was because surgery was the most dramatic part of modern medicine and would appeal most to rural people and gain their confidence. Only after surgery, and later drug based cures were well established should preventive medicine or public health be introduced to rural areas (Ellis, 1931). Ellis elaborated on these views (1932) and explained their meaning for medical education. Basic sciences would have to be stressed. As instructors and texts in these areas were not found in Thailand, instruction would have to be in English. Only relatively few students would have the proper secondary education (English, mathematics, science, etc.) to handle the programme and they would be from urban areas. To make this system operate smoothly the training of auxiliaries, the ‘Jr. Doctors’, could not be undertaken since this would dilute resources, reduce the status and demand for ‘real’ doctors and keep modern medicine from being ‘sold’ to the masses. The result of this can best be summed up by Dr Grant, an R F representative, in his 1933 appraisal of the school : ‘Public Health is still a branch of pathology . . . There is no fulltime public health man-a pediatrician and three members of the Department of Public Health in the Ministry of Interior divide up the instruction . . . Ellis takes the view that Public Health is a “speciality” and as such does not merit independent standing-and this desite the fact that as in Siam there is practically no field for private practice-except apparently in Bangkokpractically all the graduates go into Government service and 50% of these into Public Health. The instruction cannot be high grade. . . yet the School persists in retaining as a division, the field for which so far the majority of graduates have gone to after graduation! . . . policy of the R F itself . . . (is) something like putting up a building and leaving off the roof. . . The R F has brought out visiting professors for everything except the

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field in which the largest numbers go on the day of graduation.’ This situation has remained essentially the same at Siriraj to the present day as well as at Thailand’s second medical school founded in 1948 (Buri, 1970; Ministry of Public Health, 1971). The newest medical education programmes at Mahidol University appear to be maintaining this tradition. The life sciences programme described by Dinning (1974) is to staff new medical schools built on exactly the model described by Ellis in 1932. Strong emphasis on basic science, high technology, hospital based, curative medicine; instruction in English with minimal emphasis on preventive medicine and public health. Now that this type of modern medicine has been ‘sold’ to the Thais a tremendous financial effort is needed to train the personnel who will train the persopnel to carry it out. This does not seem to be a very efficient way to deal with what Dinning himself states to be the major health problems in Thailand: malnutrition, infectious disease, and excessive population growth (1974). In fact, this programme with its R F designed curricula, R F sponsored department chairman, and RF ‘identified‘ Thai successor chairmen is a complete replication of the situation at Siriraj in the 1920s. The community health programme (Buri et al., 1974) is a significant departure from the past in its announced goal of cooperation with the Ministry of Health. Yet Buri et al. (1974) note that there is no precedent for sustained cooperation and the results are still to be seen. However, in some important ways there is little change. Perhaps most significant is that there is still no independent department of public health or preventive medicine in the medical school. Buri stresses that this means that preventive medicine is everyone’s business. It may also mean that it is no one’s business or responsibility. Interestingly the programme is under the direction of the Chairman of the Department of Surgery, probably the department least oriented to preventive and community medicine. Reviewing the descriptions of courses and clerkships it is difficult to find much attention being given to preventive medicine or public health techniques. Just one example is the ‘Analysis of Health Problems’ which are viewed almost solely in terms of the health care delivery system and its ‘inadequacies’. Thus in specifying and quantifying how ‘important’ leading health problems are, ‘vulnerability to management’ as opposed to

vulnerability to prevention is a determining factor. Using this system, if a problem could be prevented but not managed once it occurred it would have ‘zero’ importance (Buri et al., 1974).

4. Developing a modern professional elite It is clear that by training small numbers of highly educated doctors to practise in well appointed hospitals and by accepting the premise that any services these doctors would offer rural areas would be in the form of short-term conscription, the RF founded programmes have historically abetted in the formation of anelite professional group whose interests are far removed from the medical problems of a rural peasant society. That this has occurred in many developing nations seems well accepted by most commentators (Bryant, 1969; Riley & Sermsri, 1974; Illich, 1969; Nairn, 1966; Lathem, 1970). However, it is usually assumed that this is an unintended consequence of such medical education programmes. While this may be largely true, it appears that, at least in the case of Thailand, there has been from the start some degree of awareness regarding the programmes’ consequences for developing a professional elite which would embody certain western values and perspectives. For example, as early as 1921 the emphasis on producing only small numbers of doctors was justified primarily on the grounds that this programme would produce the future leadership in the Thai government. It was clear to Pearce that this small number of doctors would have little direct impact on Thai health problems. The R F was quite explicit about this. In his letter to the Ministry of Education which outlined the terms under which the RF would provide assistance, Pearce acknowledged that ‘This plan looks forward to the development of a medical school training highly qualified men to assume the burden of medical leadership in Siam and to guide the developments in public health and general medical service’ (Pearce, 1922). After the agreement was signed, W. S. Carter visited Thailand and noted ‘The Siamese lack initiative and they are just as incapable of re-organizing and developing their premedical courses as they are of re-organizing their medical school. They need leadership and advisors until their own people own people can develop by special training’ (Carter, 1923). It was clear that training, not only in the techniques of western medicine, but in the entire western perspective on

Medical education in Thailand

life was needed. This was an explicitly stated reason for providing RF fellowships for study in the west for future Thai medical professors (Prince Songkla, 1923). As early as 1931, Ellis had started to specify the exact medical care structure that was needed by Thailand and which could provide the leadership positions to be filled by the schools’ graduates. Ellis foresaw a new Ministry of Health which would become independent of the Ministry of Interior and would include the present Division of Public Health, a new Division of Hospitals and Health Centres, coordinated by a Medical Council. Under this scheme the doctor dominated council would gradually extend to hospitals through the country as doctors were graduated to staff them. The then independent Division of Public Health would also become subservient to the Medical Council which itself would be dominated by the Medical School (Ellis, 1931). This plan was elaborated upon later by Ellis as a public proposal for Thailand (1932). By the early 1930s it was clear to the Thai authorities and the RF that the medical school at Siriraj would only turn out enough MDs to replace current personnel and fill a few already created government posts (Ellis, 1934; Carter, 1934). Attention was being turned to the questions of how to institutionalize their influence by altering the bureaucratic structure. One effect of this was that the type of student drawn to the early programmes was not apt to be oriented toward applying his medical skills in a traditional society but rather towards working in urban areas in or near well-equipped facilities. The scientific medical training (all in English) may well have left the students more alienated from their village culture when they finished their studies than when they began. One indication of the validity of this assessment can be found in a recent study on mobility into the medical professions in Thailand. The study found that from 1932 to 1966 between 90% and 100% of all first-year male medical students were from ‘elite social class origins’ (Maxwell, 1975). In light of the above it is useful to refer back to the programmes described by Dinning (1974) and Buri et al. (1974). Both are elitist in the types of students they select for and the type of professionals they turn out. While such elitism may be inevitable, we wish to stress that it also appears to be a selfconscious substantive emphasis of the programme. For example, the life sciences programme aims not only at training qualified teachers but at creating

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members of the ‘international community of scientists’ (Dinning, 1974). Long before the new medical schools are constructed for these people to teach in, the programme is being judged as a success based upon numbers of research articles its faculty has turned out. After completing such a programme, one should not be surprised if students are alienated from the traditional culture which they are supposed to serve. The community health programme is very similar. While it emphasizes the doctor’s role as a mediator between the rural Thai and modern medical cultures, it does so from a basically condescending perspective. In relating to communities, detached observation through surveys, and leadership as opposed to genuine participation are stressed. Systems analysis, simulation games and other ill-defined ‘space age’ techniques are used to assign priorities to rural health problems. Thus, while the community is most concerned with its need for curative medical care, the ‘community health simulation model’ judges this to be only one third as important as ‘overly large and poorly spaced families’. Malnutrition fares only slightly better in importance (Buri et al., 1974). The ‘community’ has little input or control over this community health programme.

Discussion We see two major implications arising from our work. One is methodological and one is substantive. The first concerns the need to employ a historical approach, as opposed to solely single point descriptions of medical education programmes. The meaning of some of the historical facts we have presented, especially in their influence on the present, may be ambiguous or arguable. However, to be unaware of their history renders any understanding of the present-day programmes to be fundamentally in error. It is most difficult to evaluate present and future oriented programmes without information about how resources have been used in the past and to what effect. In the case of the programmes being reviewed here, we have tried to show that they are largely repetitious of past approaches to the problem. These approaches have not been notable for great success in dealing with Thai health problems. In fact they may have made the problems more intractable. But without historical information such evaluations are difficult or impossible. Substantively, we are forced to conclude that both

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past and current programmes in Thailand have assumed as ‘given’ what the appropriate model for medical education and the delivery of health services should be. Essentially ‘western’ models have been ‘copied’ or ‘imported.’ Most authorities have concluded that the Thai decision makers eagerly took over western models of medical education and health care. But such a conclusion overlooks a key element : the impact of foreign agencies engaged in planned change. It is, perhaps, most appropriate to think of the western models as being exported rather than imported. When the historical dimension of these programmes are neglected the tendency is to avoid focusing on the conflictual nature of the ‘export-import’ process. In this case the disputes over the quantity of doctors to be produced, their quality, the role of preventive medicine in the curriculum, and the role of auxiliaries are only a few of the issues where the importing nation did not get exactly what it wanted. When historical data are brought to light it appears that the Thais themselves were somewhat more oriented to models for health care and medical education that today are identified with China and Cuba. The crucial question is to what extent did the past and continuing use of a western model, and western funding with its heavy emphasis on professionalization preclude the use of other, perhaps more appropriate, models? While we do not know the answer to this question, we do know that it will remain unanswerable until comparative historical studies supplant one country, one point in time, descriptions of medical education programmes. References BANGKOK BANK(1973) National health-The ideal and the reality. Monthly Report 14, 668. BARNES,M.D. (1921) Letter to D r Wickliffe Ross, General Director The International Health Board, 3 August 1921; RF617A. BARNES, M.D. (1924) Letter to V. G. Heiser, 4 February 1924; RG5-1 HB/D. BARNES,M.D. (1926) Letter to V. G. Heiser, 7 June 1926; RGS-IHBID. BRYANT, J. (1969) Health and the Developing World. Ithaca, Cornell University Press. BURI, P. (1970) Community medicine at the Ramathibodi hospital Faculty of medicine. Community Medicine: Teaching Research and Health Care (ed. by W. Lathem and A. Newbury), p. 105. Appleton-Century-Crofts, New York. BURI, P., BURI, R., KHANJANASTHITI, P., LIMSUWAN, A., S., BRYANT, J., STEWART, M. & WRAY,J. (1974) PHANCHET, The Ramathibodi community health programme. Journal of Medical Education. 49, 264.

CARTER,W.S. (1923) Report on the medical school in Bangkok. 14 May 1923; RF617A. CARTER,W.S. (1928a) Letter to R. M. Pearce, 16 February 1928; RF617A. CARTER,W.S. (1928b) Notes of interview with H.R.H. Prince Mahidol Songkla, 8 July 1928; RF617A. CARTER,W.S. (1933) Letter to A. G. Ellis, 19 April 1933; RF617A. CARTER,W.S. (1934) Letter to A. G. Ellis, 5 March 1934; RF617A. DINNING,J.S. (1974) University development in Thailand: a programme in the life sciences. Journal of Medical Education, 49, 763. DONALDSON, P. (1976) Foreign intervention in professional development: a case study of the Rockefeller Foundation’s involvement in a Thai medical school. International Journal of Health Services (forthcoming). ELLIS, A.G. (1923) Letter to R. M. Pearce, 16 July 1923; RF617A. ELLIS, A.G. (1929) Letter to R. M. Pearce, 18 April 1929; RF617A. ELLIS,A.G. (1931) Letter to H.R.H. Prince Sakol, 30 March 1931; RF617A. ELLIS,A.G. (1932) Medical Education and Practice. Bangkok Times Press Ltd, Bangkok. ELLIS,A.G. (1934) Letter to W. S. Carter, 15 January 1934; RF617A. GRANT,J.B. (1933) Diary; RF617A. HEISER,V.G. (1925) Memo reporting conversation with Dr Carthew, 12 December 1925; RGS-IHB/D. HEISER,V.G. (1926) Letter to Dr W. Mclntosh, 13 July 1926; RGS-IHBID. ILLICH,1. (1969) Outwitting the ‘Developed’ Countries. The New York Review of Books, 6, 20. LATHEM,W. (1970) Introduction. Community Medicine: Teaching, Research and Health Care (ed. by W. Lathem and A. Newbury), p. 1. Appleton-Century-Crofts, New York. MAXWELL, W.E. (1975) Modernization and mobility into the patrimonial medical elite in Thailand. American Journal of Sociology. 81, 465. MCFARLAND, B.B. (1958) McFarland of Siam. Vantage Press, New York. MINISTRY OF PUBLICHEALTH (1971) Public Health in Thailand. Bangkok. MINISTRY OF PUBLICHEALTH (1973) Public Health in Thailand. Bangkok. NAIRN,R. (1966) International Aid to Thailand: The New Colonialism? Yale University Press, New Haven. NIELSEN,W.A. (1972) The Big Foundation. Columbia University Press, New York. PEARCE, R.M. (1921) Report on Medical Education in Siam; RF617A. PEARCE, R.M. (1922) Letter to D. Montri, Ministry of Education, 23 January 1922; RF617A. PRINCEMAHmoL SONGKLA (1922) Letter to R. M. Pearce, 25 October 1922; RF617A. PRINCEMAHIDOL SONGKLA (1923) Letter to R. M. Pearce, 3 October 1923; RF617A. RILEY,J. & SmMsRI, S. (1974) The variegated Thai medical system as a context for birth control sevices. Working Paper No. 6, Institute for Population and Social Research, Mahidol University, Bangkok. FOUNDATION (1965) Report t o Thailand on ROCKEFELLER health services, health personnel and health education. The Rockefeller Foundation, New York. WORLDBANK(1975) Health: Sector Policy Paper of the World Bank. World Bank, Washington, D.C.