556
Overseas training for doctors from developing countries SIR,-Dr Patel and Dr Araya (Jan 11, p 110) state that "one for the dearth of research in developing countries is the lack of trained personnel", thereby again drawing attention to the belief created by doctors in the west and to the understandably frustrated expectations of overseas doctors returning back to their countries reason
with limited research facilities. But what kind of research and what type of training are they talking about? The Indian subcontinent has a doctor to population ratio ranging froml/1500 to 1/3000.1 What does it need more-adequate numbers of doctors delivering primary care, or expensive research in, for example, SPECT studies identifying brain infarcts associated with depression? What is regarded as routine research in rich countries is unnecessary in a poorly funded health-care system. Yet many people overlook the essential and appropriate research that is done-eg, oral rehydration therapy, leprosy vaccines-and that will continue to be done. Moreover, basic clinical research does not need a highly specialised and expensive research infrastructure. Clearly, every health system has to award priorities to its resource allocations-as in the Oregon approach.2 This approach emphasises that the American taxpayer is now considering whether better emergency services are more important than one liver transplant. If the trend is to allot resources mainly to basic clinical care, why should the taxpayers of third-world countries fund research that appeals to a handful of doctors who have received higher training in developed countries? What is higher training? Experience in specialties is certainly such for overseas doctors who leave their home countries with postgraduate degrees. Most overseas junior doctors in the UK come here after having already worked in their own countries for two years or more. Herein lies a fundamental difference: having had no working experience in his home country, Patel and Araya’s "Dr X" has expectations based solely on overseas training, and not on postgraduate training at home followed by higher training overseas. Patel and Araya also say that"... a senior registrar from the UK will find it nearly impossible to obtain a job at a similar level of seniority in an academic unit in some developing countries". Why should this be surprising? Senior registrars in psychiatry who have received all their training in the UK will be unable to cope in the Indian subcontinent mental health services, where, for instance, the mental health legislation is totally different. For the same reason we would have been naive to have expected to start as senior registrars or lecturers on our first appointments in the UK. Additionally, doctors on overseas sabbaticals have secure academic posts at home and, hence, higher chances of access to existing research facilities. Between us, we have a total of 11years of psychiatric experience in our countries and 4 years in the UK. Rather than disillusioned, we are, perhaps, in a position to make the best of our experience here on returning home. We not only agree with all their suggestions, but are also thankful to Patel and Araya for outlining the difficulties so succinctly. But, Sir, we do not consider ourselves to be in a "plight". Dr X is in no way representative of overseas doctors. Department of Psychiatry, St Mary’s Hospital, London W2 1NY, UK
NARESH GANDHI
Department of Psychiatry, St George’s Hospital, London SW17
PIYUSH JOHARI
Department of Psychiatry, St Mary’s Hospital
HAMID NALIYAWALA
1. World Health Organisation. World directory of medical schools. Geneva: WHO, 1988. 2. Dixon J, Welch HG. Priority setting: lessons from Oregon. Lancet 1991; 337: 891-94.
SIR,- The World Health Organisation, UK Overseas Development Administration, and other such international development agencies could profitably pay attention to the plea of Dr Patel and Dr Araya. Most overseas doctors would be intellectually and professionally far more satisfied if they could practise in their own countries. For reasons mainly related to economic uncertainty and these doctors’ inability to secure jobs for
which they are suitably qualified, they are trapped in the host country where they are rarely able to work in the specialty of their choice. This situation leads to a waste of scarce skilled manpower in developing countries and misuse of training resources of the host country. In the 1960s attention was focused on establishing links between teaching hospitals in the developed and developing world; in the 1970s primary health care became the preoccupation. Perhaps funding agencies should now direct their resources toward district hospitals, in which many returning doctors are well suited to work.’ Under the auspices of the aid organisations, serious consideration could be given to the notion of the twinning of two district hospitals-one in the developed world and the other in a developing country. Exchange visits of medical staff from various specialties would be invaluable and provide intellectual stimulation for doctors who are accustomed to work conditions in the developed world. Equipment rendered obsolete by technological advances in the developed world could be donated to the twinned hospital. This would be an invaluable asset if technological back-up and effective maintenance is provided-a frequent omission in aid programmes. The hospital league of friends will find it rewarding to take part in such schemes when they see the immense benefits that can accrue from a modest financial investment. Institution of such non-governmental voluntary projects are often characterised by great enthusiasm and flexibility in administration, planning, and employmentMost doctors returning to their home country would like to combine working in a well-run hospital with good facilities and private practice to provide financial security. In general their prospects are very good provided that they can survive the initial few years of financial struggle. Greater appreciation of these doctors’ troubles will hopefully soon lead to innovative steps by the aid organisations to find ways to alleviate the difficulties and to ensure that there is no further waste of this precious manpower. Funds allocated for training should include a component for resettlement, otherwise aid-funding agencies could be criticised on the grounds that training programmes represent a covert brain drain, not an aid programme. Many doctors still look to the west and the UK in particular for historical reasons; a continuing dialogue between British doctors and their overseas colleagues is one of the ways to give humanitarian help that should not be neglected. Public Health Laboratory, Musgrove Park Hospital,
Taunton TA1 5DB, UK
J. WYNNE JONES
1. Editorial. Front-line doctor. Lancet 1991; 338: 155-56. 2. Mavalankar DV. Health in India. Br Med J 1992; 302: 470.
Publicity and unpublished results SIR,-Professor Griffiths’ (Royal Free Hospital)
recent
appearance on national television informing the world at large that
by the use of acyclovir the death rate from HIV had been halved is at best premature, and at worst irresponsible. Patients locally, and I expect nationally, have been telephoning their doctors to ask when they are to receive acyclovir. The fact that his dramatic appearance has preceded any publication of the results put his colleagues in an embarrassing and difficult position. What is even more disturbing is to read in the Pharmaceutical Journal (Jan 4, 1992, p 10) a spokesman for Wellcome stating that the trial was not a true combination study of acyclovir with zidovudine and figures were unconfirmed. The clear impression given by Griffiths was that this was a combination study under controlled conditions and that the result was final. There is nothing to be gained and much harm to be done by such television appearances. Surely the responsible approach to such publicity is to report only the published results of material that has undergone peer review? Perhaps all doctors are of like mind, but, sadly, it may be time for a voluntary code of practice before further damage is done to the profession’s integrity. Department of Haematology, Central Laboratory, St Mary’s Hospital, Portsmouth PO3 6AG, UK
P.
J. GREEN
Overseas training for doctors from developing countries SIR,-Dr Patel and Dr Araya (Jan 11, p 110) state that "one for the dearth of research in developing countries is the lack of trained personnel", thereby again drawing attention to the belief created by doctors in the west and to the understandably frustrated expectations of overseas doctors returning back to their countries reason
with limited research facilities. But what kind of research and what type of training are they talking about? The Indian subcontinent has a doctor to population ratio ranging froml/1500 to 1/3000.1 What does it need more-adequate numbers of doctors delivering primary care, or expensive research in, for example, SPECT studies identifying brain infarcts associated with depression? What is regarded as routine research in rich countries is unnecessary in a poorly funded health-care system. Yet many people overlook the essential and appropriate research that is done-eg, oral rehydration therapy, leprosy vaccines-and that will continue to be done. Moreover, basic clinical research does not need a highly specialised and expensive research infrastructure. Clearly, every health system has to award priorities to its resource allocations-as in the Oregon approach.2 This approach emphasises that the American taxpayer is now considering whether better emergency services are more important than one liver transplant. If the trend is to allot resources mainly to basic clinical care, why should the taxpayers of third-world countries fund research that appeals to a handful of doctors who have received higher training in developed countries? What is higher training? Experience in specialties is certainly such for overseas doctors who leave their home countries with postgraduate degrees. Most overseas junior doctors in the UK come here after having already worked in their own countries for two years or more. Herein lies a fundamental difference: having had no working experience in his home country, Patel and Araya’s "Dr X" has expectations based solely on overseas training, and not on postgraduate training at home followed by higher training overseas. Patel and Araya also say that"... a senior registrar from the UK will find it nearly impossible to obtain a job at a similar level of seniority in an academic unit in some developing countries". Why should this be surprising? Senior registrars in psychiatry who have received all their training in the UK will be unable to cope in the Indian subcontinent mental health services, where, for instance, the mental health legislation is totally different. For the same reason we would have been naive to have expected to start as senior registrars or lecturers on our first appointments in the UK. Additionally, doctors on overseas sabbaticals have secure academic posts at home and, hence, higher chances of access to existing research facilities. Between us, we have a total of 11years of psychiatric experience in our countries and 4 years in the UK. Rather than disillusioned, we are, perhaps, in a position to make the best of our experience here on returning home. We not only agree with all their suggestions, but are also thankful to Patel and Araya for outlining the difficulties so succinctly. But, Sir, we do not consider ourselves to be in a "plight". Dr X is in no way representative of overseas doctors. Department of Psychiatry, St Mary’s Hospital, London W2 1NY, UK
NARESH GANDHI
Department of Psychiatry, St George’s Hospital, London SW17
PIYUSH JOHARI
Department of Psychiatry, St Mary’s Hospital
HAMID NALIYAWALA
1. World Health Organisation. World directory of medical schools. Geneva: WHO, 1988. 2. Dixon J, Welch HG. Priority setting: lessons from Oregon. Lancet 1991; 337: 891-94.
SIR,- The World Health Organisation, UK Overseas Development Administration, and other such international development agencies could profitably pay attention to the plea of Dr Patel and Dr Araya. Most overseas doctors would be intellectually and professionally far more satisfied if they could practise in their own countries. For reasons mainly related to economic uncertainty and these doctors’ inability to secure jobs for
which they are suitably qualified, they are trapped in the host country where they are rarely able to work in the specialty of their choice. This situation leads to a waste of scarce skilled manpower in developing countries and misuse of training resources of the host country. In the 1960s attention was focused on establishing links between teaching hospitals in the developed and developing world; in the 1970s primary health care became the preoccupation. Perhaps funding agencies should now direct their resources toward district hospitals, in which many returning doctors are well suited to work.’ Under the auspices of the aid organisations, serious consideration could be given to the notion of the twinning of two district hospitals-one in the developed world and the other in a developing country. Exchange visits of medical staff from various specialties would be invaluable and provide intellectual stimulation for doctors who are accustomed to work conditions in the developed world. Equipment rendered obsolete by technological advances in the developed world could be donated to the twinned hospital. This would be an invaluable asset if technological back-up and effective maintenance is provided-a frequent omission in aid programmes. The hospital league of friends will find it rewarding to take part in such schemes when they see the immense benefits that can accrue from a modest financial investment. Institution of such non-governmental voluntary projects are often characterised by great enthusiasm and flexibility in administration, planning, and employmentMost doctors returning to their home country would like to combine working in a well-run hospital with good facilities and private practice to provide financial security. In general their prospects are very good provided that they can survive the initial few years of financial struggle. Greater appreciation of these doctors’ troubles will hopefully soon lead to innovative steps by the aid organisations to find ways to alleviate the difficulties and to ensure that there is no further waste of this precious manpower. Funds allocated for training should include a component for resettlement, otherwise aid-funding agencies could be criticised on the grounds that training programmes represent a covert brain drain, not an aid programme. Many doctors still look to the west and the UK in particular for historical reasons; a continuing dialogue between British doctors and their overseas colleagues is one of the ways to give humanitarian help that should not be neglected. Public Health Laboratory, Musgrove Park Hospital,
Taunton TA1 5DB, UK
J. WYNNE JONES
1. Editorial. Front-line doctor. Lancet 1991; 338: 155-56. 2. Mavalankar DV. Health in India. Br Med J 1992; 302: 470.
Publicity and unpublished results SIR,-Professor Griffiths’ (Royal Free Hospital)
recent
appearance on national television informing the world at large that
by the use of acyclovir the death rate from HIV had been halved is at best premature, and at worst irresponsible. Patients locally, and I expect nationally, have been telephoning their doctors to ask when they are to receive acyclovir. The fact that his dramatic appearance has preceded any publication of the results put his colleagues in an embarrassing and difficult position. What is even more disturbing is to read in the Pharmaceutical Journal (Jan 4, 1992, p 10) a spokesman for Wellcome stating that the trial was not a true combination study of acyclovir with zidovudine and figures were unconfirmed. The clear impression given by Griffiths was that this was a combination study under controlled conditions and that the result was final. There is nothing to be gained and much harm to be done by such television appearances. Surely the responsible approach to such publicity is to report only the published results of material that has undergone peer review? Perhaps all doctors are of like mind, but, sadly, it may be time for a voluntary code of practice before further damage is done to the profession’s integrity. Department of Haematology, Central Laboratory, St Mary’s Hospital, Portsmouth PO3 6AG, UK
P.
J. GREEN
