The Robert D. and Helen S. Wright Fund

THE ROBERT D. WRIGHT, M.D. SCHOLARSHIP FUND

DEPARTMENT OF INTERNATIONAL HEALTH JOHNS HOPKINS UNIVERSITY SCHOOL OF HYGIENE AND PUBLIC HEALTH

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The Robert D. Wright, M.D. Scholarship Fund was established in 1981 lo commemorate Dr. Robert Wright, who was professor in the Department of International Health at the j ohns H&pkins University School of Hygiene and Public Health, from 1963 until his death in 1981.

During his years with International Health, Bob Wright spoke of the special enjoyment he experienced working with faculty, stajj and student colleagues in the Department. His major activities included working as the Departmental representative in johns H &pkins' consultative work jor the then new University of Lagos Medical School (where Bob and H elen spent jive years from 1963 to 1968 while he was Chairman of the Department of Community Medicine) and being co-director and instructor in IH-9, Teaching and Learning of Community Health.

Because he enjoyed his work in t~e Department of International H ealth so much, and because he had a strong commitment lo educational activities aimed at citizens of the entire world rather than of some particular sub-group, his family and friends began this Scholarship Fund as an approfJriate way to create a living legacy of his life.

Bob Wright was an energetic man, full of ideas and ideals. H e enjoyed putting his &pinions lo paper and he often wrote about his ideas on medicine.

Because his oum words convey the character of the man Jar better than descriptions b-y others, and because we want recipients of the Robert D. Wright, M.D. Scholarship Fund lo be able lo receive more than a financial gift from his life, we have f>ut together in this booklet a Jew of his essays on various aspects of medicine. Many of his thoughts and observations remain as relevant to medicine today as when he wrote them. We hofJe readers enjoy fl.is writings.

The Robert D. Wright Family 1984

THE IMMORALITY OF EXCELLENCE IN HEALTH CARE In this discussion I propose to show that American medicine, as it is practiced, is among the most immoral of the medical systems in developed countries and of many of the less developed countries. I will indicate by what standards this is true, the forces that have moved us to this unenviable position, and some of the forces available to correct this deficiency.

My moral text I take from Jeremiah, Chapter 8, Verses 20-22: "The harvest is past, the summer is ended, and we are not saved. For the hurt of the daughter of my people am I hun. I despair; astonishment has taken hold on me. Is there no balm in Gilead? Is there no physician there? Why then is not the health of the daughter of my people recovered?"

To make sure we are all on the same wave length and to ease the minds of those who think my title a paradox, let me give the definitions of "immorality" and "excellence." The dictionary defines immorality as "an act or practice that is inconsistent with right and noble behavior, as wickedness; likely to cause harm or trouble"; excellence as "superiority, first class."

T his discussion is based on certain assumptions: l. Throughout history, thinking humans have considered health their most prized possession. In the Gorgias dialogue Socrates says: "The highest blessing possible for a man to possess is health of the body." Jefferson agreed.

2. Health care, as the WHO has asserted, is a right, not a privilege.

3. A health care system should be for all the people.

4. Governments are instituted to assist the people to accomplish those things they cannot do well or do at all on their own.

Before we apply the brand of immorality to a great profession, it is only fair that the brand be placed in perspective. A hundred years ago the conscience of mankind W<?uld not by any stretch of the imagination have considered the medical profession immoral on the basis of the

Note: This essay was written in 1972, as a Sunday sermon which Bob Wright delivered in the Thomas Jefferson Memorial Unitarian Universalise Church, Charlottesville, Virginia.

The Wrights were active members of the church for over 30 years. In addition to giving an occasional sermon, Bob sang in the choir and chaired search comminees when new ministers were needed. Helen was church organist, board member and Alliance president. The essay was published in the Virginia Quanerly Review (Volume 50, Number 2) in 1974 and is reproduced here with permission.

above assumptions. Arnold Toynbee has said that when in the far distant future historians come to assess the unique qualities of the twentieth century, one will stand out above all the rest: it was in the twentieth century that man, for the first time in his long history, began to think about the welfare of all mankind. Always before, the concern was limited by sex, class, race, blood, citizenship. And in no area of human concern has this lifting of the limits been more pronounced than in the field of health. When the WHO speaks of eradicating malaria, or small pox, or tuberculosis, it is not just from the men, the whites, the affluent but from every last human on earth.

This is a whole new dimension to our thinking and American medicine has not yet caught up with it. The great names in man's move to a universal base for h ealth and medical care have not been doctors but laymen such as Chadwick, George and Beveridge in England; Shattuck, Wagner, Reuther, and Falk in the United States; Bismarck in Germany; Lenin in the U.S.S.R.; and Mao Tse-tung in China. True, occasional prescient practitioners were the driving urge behind statesmen, but not organized medicine. Nor is this surprising. Medicine in its origins and its development has been, with few exceptions, concerned with individuals rather than groups. Almost the entire training of doctors has been concerned with one-to-one relationships.

During the twentieth century this one-to-one relationship has undergone drastic changes. When the doctor had a few potent drugs and only. heroic surgery at his command, he had to concern himself with the patient's habits and environment. Now with a bag crammed full of dramatic and dubious drugs, with surgical colleagues at his elbow sporting a myriad of tricks, the doctor can see fifty patients a day instead of six, without taking the time to influence the patient toward a more salubrious way of life.

As the century dawned, America had, by world standards, a very large doctor supply and a fantastic number of medical schools - one to every 500,000 against today's one to every 2,000,000. The quality of most of these 166 turn-of-the century medical schools was, by scientific standards, low indeed, Kansas City with a population of 164,000 in 1900, had thirteen of these schools. In the middle 1930's as a health. officer in the Ozarks, I worked with some of the graduates of these schools. Many didn't know one end of the microscope from the other.

As a recent graduate of one of America's "best" medical schools, I came to the Ozarks ready to scoff, but as more wisdom dawned I remained to pray. These graduates of the diploma mills knew precious little about the d ynami-E:s of modern drugs or the chemistry of the blood, but the successful among them had two strengths that every last soul am.ong the sick needed and longed for. First they had time, time to establish that mystic patient-doctor relationship that lives below the le\'el

of thought and feeds on the second strength. These non- or littlescientific doctors knew in their bones that "care" was a verb before it became a noun and that to the midbrain where the survival urge resides, the verb is more important than the noun. Man, the herd animal, once he becomes unhealthy - unwhole - seeks to supply the missing factor from another member of the herd who cares about his unwholeness. Through the centuries, we have institutionalized this caring in a medical profession. The basic, midbrain desire is for some one who cares about our unwholeness. But as thinking animals we go beyond this to desire one who cares wisely, and yet most men and women settle for the first if they can't get both. Caring and time are the anatomy of consolation, and consolation is the deep down desire of the sick. Not so deep but powerful in a technological society, is the desire that the professionals care wisely.

In the first decade of this century a young educator from Louisville, Kentucky, was worrying about the lack of attention to science in medicine. The Carnegie Foundation had made him a grant to assess the quality of medical education in the United States. Abraham Flexner's report was a bombshell that not only shocked America, but Europe even more so. Under its impact, the whole thrust of medical preparation turned from consolation to cure or control of the patient's disease through science. In medical academe Flexner becanie a saint and as is usual with saints, the tendency, generation after generation, is to adore rather than to question. Flexner's report resulted in a great improvement in the medical student's understanding of the mechanism of certain diseases. Eventually, it resulted in a flood of public and private money for laboratory research down to the most esoteric of the exotic.

For many years I was one of those who adored St. Abraham Flexner, but now I think I have reached the age of reason. Somewhere along the way, perhaps as the result of a serious illness, I began to ask questions. Others are asking questions, among them the Nobelist, Mcfarlane Burnett of Australia, Thomas McKeown of England and George Silver of the United States.¡ Flexner made two basic assumptions for which he had no factual data: (l) that the quality of medical education was a prime determinant of the health of the people; and (2) that the scientific approach would provide the kind of health care the people needed and wanted.

Burnett, after a lifetime in the laboratory and a Nobel Prize to show for it, has concluded that molecular biology has contributed little, if anything - and nothing at all since 1955 - to health and that the whole period of laboratory science and the engineering approach to medicine which began in the seventeenth century with Harvey's discovery of the circulation of the blood, has come to an end. McKeown has presented

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convincing evidence through historical review that improvement in the health of the British and the Swedes predated both the industrial and the scientific revolutions. He concludes from his studies that "the improvement of human health.. .is due primarily to a modification of human behavior or to the adaptions to the environment in which man is placed." The most significant modification of behavior, he believes, was the decision human beings made to limit family size. Among environmental changes he considers most important improvement of food supplies, followed by removal of threats from the physical environment; finally - and much later - specific measures to prevent and treat disease such as with vaccination. But not until well into the twentieth century did these latter measures become sufficiently effective to influence affairs profoundly at the national level. As McKeown sees it, major diseases are either preventable or intractable and therefore our concept of medical effort should be primarily the care of the sick rather than the cure of disease. Increase in life expectancy of population has come, for the most part, not because of improvements in treatment of the sick, but because of a decrease in the numbers who get sick.

Let us examine these concepts in the light of modern professional medical practice. I spent five years in West Africa, where for uncounted centuries one-half of all children born alive have d ied before the age of five. Nigeria has 60,000,000 people and only 2,500 doctors. ¡ It also has a very large but undetermined number of indigenous healers. The doctors are all trained in the ethos and technologies of Western medicine. The country had accepted without question the English laws which prohibit any trained worker below the level of a doctor from acting as a primary care agent in the care of the sick, thus severely limiting the possible contribution of nurses and midwives. Fortunately, in this instance, the laws are poorly enforced in most of Nigeria. In the I 950's an English pediatrician decided to see what could be done to lower the death rate among children under five years of age in a bush village using a nurse and lowgrade local midwives plus backup by a visiting pediatrician one-half day a week.

The midwives had our equivalent of primary schooling plus eighteen months of book and bedside training. At the start, out of 1,000 children born alive, 295 died in infancy and another 277 before five years of age. After seven years of the program the death rate had taken an incredible tumble to fifty-three per 1,000 in the first year and eighteen per 1,000 in the one to five ages. One of my doctoral students, Dr. Nicholas Cunningham, who spent a year making this study of the village program, concluded that the most significant change leading from the high death rate to the low death rate was in the behavior of the mothers. They changed not only the constituents of the food, but the methods of preparing and giving it. Then, in the midst of a dirty 4

macroenvironment, the mothers were taught to create a clean microenvironment for the newborn, and to bring the child to the clinic at the first signs of illness. These dramatic results were achieved with very little technology - alJ of it known before Flexner was heard of.

The doctors of Nigeria have known about these' findings for five years and yet the practicing doctors in their organization or in government have made no move to translate these findings into a national program of child saving and child spacing. Millions of life years are at stake, but "there is no physician there."

Yet, before we look down our noses at 1\igerian doctors let me hasten to reveal that these findings were presented at the same time to an international meeting of pediatricians from all over the world, including the United States. Few countries have changed their laws to permit primary decision making by nurses or anyone below the level of a doctor in health care. Since that meeting, the American medical profession has made hesitant moves in the direction of enlarging the decision making scope of nurses and other auxiliaries, but the movement is minuscule and heavily hedged.

In the less developed countries a division of labor and authority in the health hierarchy is a life and death matter. For countries like Nigeria there is no hope of getting a moral balance between entry into and exit from life except through primary decision making auxiliary medical personnel. At present the bulk of the private practitioners in these countries are neither participants nor spectators to this problem.

For them it doesn't exist. They are too busy - being excellent with their patients.

In the developed countries such as the U.S., Britain and Sweden the problem has a different impact. Here the non-medical forces of affluence have already markedly changed our reproductive behavior, have improved the food supply and have greatly reduced threats from the physical environment, though much remains to be done in the areas of violence and poisons. Here the pressing need is for more care (verb, if you please) for the truly sick and more habit change for the not-yet-sick. This is not to suggest that technology be thrown out the window. It is to suggest a reordering of priorities to structure a moral health system.

And what is a moral health system? I would suggest a moral health system model would do the following: 1. It addresses itself to the major health needs of the people.

2. It puts major emphasis on health maintenance.

3. It provides available health services to every citizen on the basis of need regardless of all other considerations. T o this end it rationally

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relates the complexity of the facility and service to the complexity of the needs.

4. It is so organized that it provides a reasonable value per unit of cost.

5. It assures the providers sufficent return in money and job satisfaction to attract the talent and dedication necessary to service and development.

6. It satisfies the felt needs of the citizens.

7. It does no harm.

How does American Medicine measure up to such a model? The average medical school, much less the average practitioner does not even inquire into the major h ealth needs of the people. They are not set up to deal with health needs but rather to deal with those diseases which have become intractable enough to bring the patient to the doctor. They are set up to deal with the numerator, not the denominator. Recently the President of the AMA told the National Conference of Rural Health, "Physicians today in general are trained to diagnose disease and disability and to treat them. Their mission in life is, almost by definition, one of sickness care. To talk of converting them to a majc:r concern with maintenance of good health is to seriously misunderstand the p ractice of medicine." If Dr. Roth is right, this rules out physician participation in the second part of the moral model also.

In the third provision of the model, universal availability of services, neither organized nor unorganized physicians have played a significant part. The history of medicine has provided no guidelines. The present guidelines are virtually all in socialist or semi-socialist countries (I avoid the word communist because there are, strictly speaking, no communist countries). You can imagine how many socialist doctors there are in the United States.

Reasonable value per unit of cost has not been a concern of physicians. The standard answer to anyone who questions has been, "How much do you think your life is worth?" On occasion this has to be faced by the widow of a dead husband, such as in the extreme case of the Detroit worker who was admitted to the hospital fo.r an eye operation only to suffer a massive heart attack while awaiting his turn for surgery. In twenty-nine hours of heroics between admission and death the doctors and hospital ran up costs of $7,300. Even after insurance and belated Red Cross help, the widow owed $1,000.

Provision number five, adequate remuneration, is taken care of beyond the profession's wildest dreams of a generation ago. When the American Commission on the Costs of Medical Care made its landmark

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study in 1928-32, practicing doctors had average incomes around $5,000 per year. Now the average is close the $50,000.

For provision number six, citizen satisfaction, the modern doctor should be crowding the peak. He is not. As the number of patients has gone up the satisfaction has gone down. In the last six years alone, according to a recent Harris survey, the citizens who have great confidence in American medicine have fallen from 72 per cent to 48 per cent. Professor ='Jeal .Bricker speaking on the subject, "Medicine 1984," sees American medicine on the edge of disaster because the profession has failed to address itself to the problem of moving from a selected to a universal base of medical services within the professional means available.

Provision number seven - do no harm. It is sad to have to comment on this in a general way but one must. In any system run by human beings, harm will be done occasionally, but when harm is done wholesale it must receive wholesale attention. In medicine harm can and is done not only by malfeasance and misfeasance but by nonfeasance. Why is it that a woman is four times as likely to lose her uterus if she lives in California as she is if she lives in England and Wales, and 80 per cent more than in the rest of the United States? Why do the American people undergo twice as much surgery as they do in England, a country with better life expectancy than we have? Even in our own country, surgery is twice as frequent under fee-for-service programs as under pre-paid group practice, such as Kaiser. Why is the incidence of surgery proportional to the incidence of surgeons? Why did Herbert Denenberg, Insurance Commissioner of Pennsylvania, have to write a shopper's guide for surgery for the people of his state?

(Surely, this is the ultimate professional insult.) Why did the children of the poor remain without the protection of immunizations until the rising level of government concern forced the issue in spite of lobbies?

Why has the AMA steadfastly opposed any reorganization of health care delivery that will disturb the present mode while much of the inner city population is almost as devoid of primary care as the African bush?

Concern in the profession over the deficiencies in our approach to health care is perhaps more widespread than at any time before. Those who read history know that changes will come from within or without.

Dr. Neal Bricker (looking forward to 1984), while all in favor of "excellence", that is, excellent science and research, suggests that irs champions must meet the people's needs if they would preserve their strategy of "excellence''. To accomplish this he sees the need for a new division of labor within medicine and a great increase in the use of the computer. If doctors are to remain at the high income levels they have attained (largely by default), they must function throughout the day at 7

a high level of decision- making and technical competence. A vast increase in the number of paramedicals trained to do much that a doctor now does will be required. He is very wary of any generalists among the paramedicals. (It would be too easy for them to become entrepreneurs?)

Bricker sees computers as storage houses for all the medical facts on all the people. He sees them able to take histories, do differential diagnosis, suggest laboratory tests and types of treatment. They can even provide part of the back up for the paramedics. Bricker and Schwartz see the computer as an instrument to "help free the physician to concentrate on the tasks that are uniquely human such as the application of bedside skills, the management of the emotional aspects of disease, and the exercise of good judgment in the non-quantifiable areas of clinical care."

And so, we come full circle back to the nineteenth-century expert in consolation backed up now by ivory-tower scientists whose brains have been picked by computers. It is an attractive idea except .for a few deficiencies: 1. All of the physician input is still on sickness. Health maintenance and ¡behavioral change go begging.

2. Instead of paying $10,000 a year per consoler plus computer costs, the public will be paying $50,000 per consoler and computer costs. We have no evidence that the present day consoler is any better than, nay, that he is as good as, the old $10,000 modeL What we need in this country is not a great increase in the present breed of doctors but a decrease and the creation of a Bachelor of Medicine, a hybrid doctor-nurse, who can be in practice five years after high school, who ¡ can handle at least 80 per cent of all the medical problems now reaching primary-care doctors (with high-cost specialists handling the rest), one who will have the time necessary to establish rapport, meet emotional needs now unsatisfied, and be what the word doctor means - teacher, behavior changer. In transition, thousands of nurses with B.S. degrees could become practitioners with one year of training: Such a plan will not work unless the doctors like it, or cooperate because they must for it to survive. We know it will work because its essential elements have been tried with doctors who wanted it to succeed. A Bachelor of Medicine system of primary care for all the people might in the end cost no less than the present non-system, but the dividends could be far greater.

The essence of all this is that practitioners throughout history have had major concern with only a small part of the total health needs and desires of the whole community. Their training has eminently fitted them to do what they are interested in doing but their practice models

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and their medical schools have poorly prepared them for the larger goal.

Many years ago I had breakfast in Geneva with one of the greatest larger-goal doctors of this century, Andre Stampar of Yugoslavia. We were discussing the massive resistance of American doctors to any type of health care planning. He looked out of the window and mused, "You will see, in America you will have the same experience we and the other countries of Europe have had, because doctors are the same everywhere. In Yugoslavia the people kept asking the profession questions about health care delivery and we always answered. 'No.' Finally, the people quit asking us questions and gave us the answers."

Perhaps that is as it should be. Harold Laski once said, "Always keep the experts on tap but never on top." Perhaps it is asking too much that the professionals with a vested interest, whether they be doctors or lawyers or teachers or, yes, preachers should see and fight for the largest moral dimensions of their acts and omissions. No doubt this is the reason why Thomas Jefferson put so much faith in the collective wisdom of an informed citizenry. If this moral blind spot exists in the profession, and I believe it does, the best advice might come from a paraphrase of a great statesman's wartime dictum: The health of the people is too important to¡ leave to the generals of medicine.

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A CAREER IN MEDICINE October 21, 1960 Dear Sue, I have been thinking about your favorite science professor's intimation that the calling of medicine is a low goal for a high intellect.

In academic life the real payoff is not the salary, but the joy of experiencing fine intellects who portend greatness. Even at Swarthmore this is a rare commodity. Ever so many high I.Q.'s end up in low places because they are hitched to midbrains with no fire or midbrains that backfire. The true instructor, who sees a student with both boiling in high balance, hopes and prays his charge will make her goal some galaxy that will fire her mind lo objectivity to the very end.

Is this possible in medicine? Perhaps not in the kind of medicine most.patients know. Perhaps this is the kind of medi.cine your instructor is thinking of, the kind of medicine that is tangled in the web of trade. It is not medicine that pulls men down, but rather it is our cupid system that keeps the calling lower than the angels. But even with all the pulling it remains far higher than the crowd. Benjamin Franklin felt this so keenly he looked on physicians as citizens of the world the enerriy of none and the friend of all mankind. He said physicians, even though attached to armies, should never be considered a party to conflict and if captured should immediately be traded back to the enemy.

Robert Louis Stevenson probably penned the most flowery tribute of the best in us, though I fear he was less than objective about us and less than fair about the others when he wrote: "T here are men and classes of men that stand above the common herd: the soldier. the sailor, and the shepherd not infrequently; the anist rarely; rarelier still the clergyman; the physician almost as a rule. He is the flower (such as it is) of our ci,¡ilization. and when that stage of man is done with, and only remembered to be man¡elled at in history, he wi ll be-thuught to have shared as little as any in the defects of the peri<>d. and most notably exhibited the virtues of the race".

Note: This letter, to the Wright's second daughter, Suzanne, was wriJte11 in 1960 when she as a college soph()more trying to decide about a career i11 medici11e. The letter worked.

It is lucky for the world that most physicians are willing to settle for something less than that pristine objectivity of pure science which none of your instructors has reached, but many hope to see achieved in some student.

Pa tients almost never accuse a physician of being too warm hearted.

The art of medicine, like the art of anything, is a rich mixture of forebrain and midbrain. Midbrain alone gives fire without direction.

Forebrain alo9e gives direction without fire. The academician more than..others sees the havoc that has been wrought through history by overwhelming emotion with inadequate intellectual force to give balance. (Our Unitarianism is a reaction to unbridled emotionalism in religion - perhaps too great a reaction.) Your instructors- some of them - are aware of the enormous self-discipline required to bring objectivity into ascendency over subjectivity. It is this realization that makes them worship (I doubt if that is too strong a word) objectivity as Good.

In medicine, and to me this is its finest attribute, there is more scope

for the development of a rich and constructive balance between the intellect and emotion than in any other human endeavor. When you h ave been with men as they met their Maker, when you have shared the joy of mother and child in Life Emergent, penicillin becomes more than a "shot." The physician who has listened to the emotion laden "history" of a patient and felt her quiver as he laid examining hands upon her, and, when the ordeal was done, has sat down to use his intellect to bring an objective picture out of this mixture of subjectivity and objectivity, knows what the professor meant when he said, "Medicine is an art based on science."

Another satisfaction in medical life not equally shared, I believe, in any other profession is the..daily, yes hourly, opportunity to help others without judging them. Not even ministers and priests are as free in this. If a man is bleeding, we do not ask if he deserves a clamp. If he has pneumonia after a binge, we do not ask if he deserves penicillin.

The physician helps because the patient needs help.

These are satisfactions I knew only briefly, but I would consider my medical education worth the price even if I had decided, after my hospital work, to become a minister or a carpenter. Such experience molds the mind. It makes it possible for many of us ordinary mortals to view humanity with all their foibles as Franklin, in his genius, did through indulgent eyes. Physicians know that every man has feet of clay.

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Medicine holds many other resources for satisfaction. Laboratories are full of M.D's getting their kick out of chasing The Bird of Truth. I once caught a pin feather or two from that bird myself. Your instructors may say a "M.D." is a waste of time for the researcher. This is a limited view. In a number of medical schools it is possible for bright students to take a five-year course ending in a M.D. and M.S. in research. During the last three years of the five the student works half the time in a "Ph.D. atmosphere." At Harvard they are having Ph.D. candidates and selected M.D. candidates work together. No doubt this will spread.

.In any event, I can love a daughter with all my heart who has examined her life and made her own decision about the use of it.

Whatever the decision, it is likely to be good if the process is good.

"Look then Think."

Love, Your Daddy

Another reason for the "M.D." in medical research is its value in working with people. Many observations must be made on the whole person not just his blood or excretions. This is particularly true in that great unknown and largely unexplored area - the mind.

Still another source of satisfaction is administrative or "wholesale" medicine where I have spent most of my time. The satisfactions are not as intimate, but they are real - at least to me. I take much satisfaction from the knowledge that I was part of the team which developed the treatment. schedules that proved to the world that penicillin cures syphilis and part of the administrative complex that translated this knowledge into treatment programs which knocked the peak off a disease that had baffled and killed. millions through the centuries.

Do not decide for or against medicine on the basis of its ability to challenge your intellect. It can make your thinker sweat blood. Make your decision on the basis of how you think it can add or detract from your total fulfillment. One caution - when you have made your decision, don't try to justify it to anyone. As the old judge said to the new judge, "Give your decision without fear. You ¡will probably be right. But never give your reasons. They are sure to be wrong." Our large decisions are the product of our total experience and much of that cannot be verbalized even with a will.

And be assured, I have not told you these things to surround you with a web of reasons from which you cannot escape. If I am overboard on the calling of medicine, put it down to honest prejudice due to a limited experience in this limited life.

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BENJAMIN FRAN KLIN'S GREATEST DISCOVERY Mr. Chair, Honorable Members of the Maryland Public Health Association, and other Gentle Persons, I come to praise Dr. Franklin not to bury him. The good he did lives on, the evil, what little he had, lies buried with his bones. May you be as lucky.

When Nancy Palmer asked me to do a Bicentennial on my long time hero and role model I was delighted not only because I would be among Public H ealth wor kers, but for a very selfish reason-it gave me a chance to spend delicious hours re-reading my books on this fantastic American about whom someone has said, "He must be real because nobody could have invented him". From this re-reading I found I have to change the title of my remarks to "Dr. Benjamin Franklin's Greatest Discovery".

T alking about Dr. Franklin is a pleasure, but a frustration as well for the temptation is enormous to try to tell something fascinating about every side of this universal genius, this printer, journalist, scientist, politician, d iplomat, educator, organizer, writer, philosopher, inventor.

On h is death Mirabeau in Paris proclaimed to his fellow legislators, "Antiquity would have raised altars to this mighty genius, who, to the advantage of mankind, encompassing in his mind the heavens and the earth, was able to restrain alike thunderbolts and tyrants." After this oratorical flourish the French Assembly closed down for three days of mourning in Franklin's honor. (Our Congress didn't even scop for a moment of silence. Washington was afraid it might set a precedent.)

Fr anklin was a man for all seasons and, it appears, for all centuries.

As historian H enry Steele Commager said on the 250th anniversary of his birth, "He is the most contemporary of the Founding Fathers, the only one,. ... ., who would get along famously in the America-of our own day." May I suggest, if we want a personal model for our third century, if we want a model to help us regain belief in ourselves, Franklin is the man above all others.

Note: Bob Wright's favorite hero was Benjamin Franklin. In many ways he sought to pattern his life after Franklin more than any other single person, partkularly with his sense of curiosity which, like that of his hem, seemed to have no bounds. This address on Franklin was delivered in 1976, the American Biceiilennial, to the Maryland Public Heallh Association.

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As we think in the next few minutes, about Franklin the scientist, the medical hypothesizer, the_behavioral experimenter, let us keep in mind the setting. He was a p rinter, first, last and always. Even as the 78 year old ambassador to France and the most renowned scientist in the world (if we can believe his severest critic, John Adams) he had a private printing press in his quarters at Passy. His will, written in his 80's begins, "I , B. Franklin, Printer,". H is famous epitaph which he wrote in his leather apron days when he was 23 years old, and is on his tomb today, reads: "The body of B. Franklin, Printer, (Like the Cover of an Old Book Its Contents tom out and Script of its Lettering and Gilding) Lies here, Food for Worms. But the Work shall not be lost; For it will (as he believ'd) appear once more in a new and more elegant ÂŁdition, Revised and Corrected by the Author." Keep in mind that for thirty years, while he was grinding out his deathless commentaries on buman behavior as the sayings of "Poor Richard", while he was inventing, hypothesizing, investigating, organizing, he was wearing a leather apron in the press r oom at least six hours a day six days a week.

We must also keep in mind that he lived before the information and research explosion, when instead of formalized articles imponant ideas were set forth in letters or short essays. And one other thing to keep in mind: from the time Poor Richard's Almanac became popular in Franklin's twenties virtually everything he wrote whether in private or in public became something for the public to ponder.

Franklin concentrated on science for only seven years of his 84 years, although he maintained a searching interest in (as they said) "Philosophy" a ll his life. On his last Atlanta voyage, as an old and honored statesman returning to his beloved country, he wrote three scientific essays.

At 42, long after most scientists have made their important contributions to knowledge, Franklin retired from business to devote himself fulltime to philosophical inquiries. Franklin's greatness among h is fell ow scientists rested in the first instance on his contributions to understanding electricity but almost as much on his contributions to an understanding of population dynamics.

Nobelist Robert Millican called Franklin's single fluid hypothesis "probably the most fundamental discovery in the field of electricity. It was he," said Millican, "who with amazing insight laid the real foundations on which the whole superstructure of electrical theory, and interpretation has been built." Had there been a Nobel Prize in his day it cannot be doubted he would have received at least one for science and one for peace.

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Franklin's discoveries, as related in letters to Peter Collinson, so impressed the Royal Society they eventually awarded him the Copely Gold Medal, their highest honor, and elected him a fellow.

Out of all this, of course, came, as every school boy knows, the kite, the key and the lightning rod but it was 150 years before science reached a consensus that this single fluid theory was correct, nor do many know that his letters contained for the first time- at least in English-such words as armature, battery, brush, charged, charging, condense, conductor, discharge, electrical shock, electrician, electrify, Leyden Bottle, minus, negative, non-conducting, non-conductor, nonelectric, plus, positive, stroke (for electric shock), uncharged. His experiments established him in Science. His lightning rod helped make him a household word throughout America and Europe. His only medical use of electricity was experimental shock therapy fo r the palsy but he concluded the benefits were more "from the spirits given by the hope of success enabling them to exert more strength in moving their limbs."

Franklin's contributions to medicine and hygiene, like those in so many other fields, grew out of boundless curiosity and need. If Franklin had not been so eminent in other fields, we might very well know Franklin as one of the Founding Fathers of American medicine and hygiene. He was a member of the Royal Medical Society of Paris, an honorary member of the Medical Society of London and a member of several medical societies in the U.S. As a champion of exercise, fresh air, bathing and moderation in food and drink he stands as an American pioneer in the field of personal hygiene. His statistical studies of the benefits of smallpox inoculation, his essay on population dynamics, his observations on the epidemiology of lead poisoning and his shrewd , accurate hypothesis on the epidemiology of upper respiratory infections attest to his discerning interest in preventive medicine. To ophthalmology he contributed bifocal lenses, to urology a flexible silver catheter. His experimental approach to the unmasking of Mesmerism makes psychiatry his debtor.

He was the driving force that made Dr. Thomas Bond's dream of a first hospital in America come true and for the first medical school to be established. Thomas Bond was a Maryland boy who went to Europe for his medical education and then headed for the big city (I think Philadelphia had a population of about I 5,000 then). When Bond tried to promote the building of a hospital everyone of any consequence he asked for money invariably answered with, "What does Franklin think of this?" So he went down to the print shop for a talk with the president of "The Leather Apron Club", the granddaddy of all Rotary 16

and other "service" clubs. Franklin thought the hospital a great idea.

He immediately proceeded to prepare the public mind with articles. in his Pennsylvania Gazette. He printed subscription lists and put bis own name at the top with the gift of 25 pounds, equal to half a year's salary for most workers. Then he concocted a plan that has become the warp and woof of federal-state relations down to this daythe grant-in-aid or matching funds. As secretary to the Colonial legislature he drew up a Conditional bill of assistance: if the citizens would raise so much money, the legislature would match it. Then he put the sum so high, 2,000 pounds, the members figured it was utterly impossible to raise it; hence, if they agreed to the plan, they conceived they might have the credit of being charitable without the expense.

Thereupon they agreed to its passage. Immediately, the solicitors were able to say to the people, "Every pouad you give will be doubled by the legislative gift". Wrote Franklin in his autobiography, "The suscriptions accordingly soon exceeded the requisite sum..and I do not remember any of my political maneuvers, the success of which gave me at the same time, more pleasure, or wherein , after thinking of it, I more easily excused myself for having made use of cunning".

Some years before the hospital episode Franklin's interest in fresh air led him into an investigation of the heating and ventilation of houses and out of this came the Pennsylvania Fire Place (now known as the "Ftanklin Stove") which ch anged the indoors environment of millions in the U.S. and Europe for 5 months out of a year; and also came his theory on the epidemiology of "colds". Another force urging him on was the increasing smog in the growing City and the increasing distances-up to 100 miles-that wood was being hauled for heating.

Stoves had been known in Europe for many years but their deficiencies were considerable. Franklin's Fireplace (which he refused to patent) provided warmed fresh air through a duct from the outside leading to a labrinth in the stove and preserved the pleasure of the open fire place. Using both convection and radiation he was able to heat the whole room so that the inhabitants would no longer roast in front and freeze l:?ehind. Some users were able to reduce wood consumption to a mere 15% of what a standard fireplace required. Though the Pennsylvania Fireplace helped make Franklin a household name throughout America and Europe, there is only one in existence today and that in the Franklin Museum, made from his original drawings: The so-called "Franklin Stoves" of today would not be recognized by the author. They are free standing fireplaces with no heating labyrinth for the fresh air component so dear to Ben. Later, in a letter to Dr. Ingenhouz, physician to Queen ¡Maria Theresa, he discussed at length the subject of fresh air, dampness and 17

colds wherein he postulated, "I imagine it is a cause that renders the air in dose Rooms, where the perspirable matter is breathed over and over again by a number of assembled People, so hunful to health.

After being in such a situation, many find themselves affected by that Febricula, which the English alone call a cold, and perhaps from the Name, imagine. that they caught the Malady by going out of the room, when it was in fact being in it." Thus close- to the germ theory of upper respiratory 'disease did Franklin come.

they could find no solid evidence that he was a rounder. One might say, rather, he was a teaser. He had an ipso facto love for all handsome and intelligent women and wrote them literally hundreds of letters, some of them, especially to the French ladies, quite provocative by our standards, but then, to them, as a rotund and happy septuagenarian, he was "Papa" Franklin - a father figure. He confesses in his autobiography to a commerce with low women in his youth and how thankful he felt he had not contacted V.D.

Franklin was an ardent advocate of Lady Montagu's inoculation against smallpox in the days of vaccination. He prevailed on one of his London friends, the great Dr. William Heberden, to write a defense of the practice. For the pamphlet Franklin provided a four page preface in which he presented statistics from Boston and Philadelphia demonstrating:

Beyond his many short comments and aphorisms on sex in Poor Richard his two major contributions to sexology are a letter-at least he wrote it in the form of a letter, but it is really a To-Whom-It-MayConcem-on the choice of a mistress in which he first makes out a case for marriage as the proper remedy, but should- that be rejected he makes out a thoroughly documented case in favor of choosing an old woman over a young one. He gives, at length, eight sensible reasons. I wish I had time to read them all. The last with two exclamation marks reads, "They are so grateful!!"

- that inoculation of otherwise healthy children and adu lts produce 5 to IO deatlis per I 000 inoculated whereas smallpox caught in the common way produced 150 to 250 deaths per 1000; and in that day virtually everyone got smallpox sooner or later.

Franklin had a long time interest in lead poisoning which began as a boy when he heard of the dry bellyache in people who drank rum distilled through lead worms, and later in his teens in London when he observed palsies in printers who heated their lead types before composing. He noted the toxicity of white lead paint and the danger of drinking even slightly acid ¡water that has passed over lead. He ended his dissertation on lead poisoning with: "You will see, that the opinion of this mischievous effect from lead is at least 60 years old; and you will observe with concern how long a useful truth may be known and exists, before it ¡is generally received and practiced on". Today he no doubt would say the same thing about tobacco, which, by the way, he never used.

Franklin had a life-long interest in population. Indeed John and Abigail Adams thought he had altogether too much interest in increasing the population. It is true that two year old William Franklin seemed to have come out of the wall almost immediately after Franklin married his one and only spouse, Deborah (nee') Read. William, who became the Tory Governor of New Jersey had a similar experience while studying in Lo~on and his son, Temple, had a similar experience while a youthful secretary to his grandfather in Paris. It sort of ran in the family. Recent investigations by two well qualified lady biographers support the impression that Franklin did indeed have both a personal and a scientific interest in sex and its products but after his marriage 18

Franklin's other contribution was "The Speech of Polly Baker" which he wrote anonymously in his early 40's and did not reveal authorship of until he was past 80. It contains in humorous satire the full thrust of his expansionist ideas on the population dynamics of North America as set forth in a carefully drawn essay written in the ~ame general period of his life. Polly Baker was reprinted in "The Gentleman's Magazine" and in about every other magazine of importance throughout Europe, His essay on population was also widely read throughout England and Europe and both Malthus and Adam Smith acknowledged their debt to Franklin in the development of their own works.

Polly Baker was being tried by a panel of Connecticut judges for the

fifth time for having a bastard child. She humbly petitions fot mercy and then proceeds (in part) with, "Abstracted from the law I cannot conceive, your honors, what the nature of my offense is. I have brought five children into the world at the risk of my life. I have maintained them well by my own industry. Can it be a crime (in the nature of things I mean) to add to the king's subjects in a new country that really wants people? I defy anyone to say I ever ~efused an offer (of marriage)." Theil she relates that one of the absent magistrates got her pregnant the first time through a sham proposal of marriage.

She pleads that they "quit making laws that turn natural and useful actions into crimes" and calls for a double fornication tax on bachelors

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to force them into marriage. And finally she calls the Bible to her aid with the duty of the first and greatest command of nature and Nature's God* Increase and Multiply; "A duty", she declares, "from the steady performance of which, nothing has been able to deter me, and I therefore, ought, in my humble opinion, instead of a whipping, to have a statue erected in my memory".

Polly's plea induced the judges to dispense with the charge; and one of the judges married her the next day-by whom she had 15 children.

Here we see Franklin at his best with satire that causes no pain and powerfully makes his p oints which the scliGlarly treatise, "Observation concerning the Increase of Mankind" analyzed in depth. He saw early marriage as the chief factor in expanding the population and set forth all the factors favoring or hindering it. With amazing insight he postulated eight births per marriage in the new world against four in the old and reckoned a doubling of the population each 20 years which, in fact, it did for the nexL l 00 years!

You will recall the title for these remarks was "Benjamin Franklin's Greatest· Discovery." For me, and I am confident for the world, it was not electricity or population d ynamics but rather a discovery about himself that made it possible for him to influence an age and the ages.

It is said that the great advances in health yet to come will be in population control, detoxification of the environment and changes in personal habits. Franklin was concerned with environmental toxicity in his own day and I feel sure he would long since have changed his ideas about an uncontrolled expansion of the population. It was in the field of personal habits however, that he made his greatest discovery. From his earliest youth there was a strong streak of pride in Franklin. We have only hints from the record to go by but he must have been an irritating brat and a real cross for his brother James to bear during the truncated apprenticeship from which he ran away. He appears to have discovered the imperative mood when most children were lisping their first words. He knew all the answers and was proud to tell them. He couldn't remember a time when he didn't know how to read. He cut his baby teeth on john Bunyan's Pilgrim's Progress and then proceeded to read everything Bunyan ever wrote. At 12 years he was hawking his own poetry through the streets of Boston. Before the end of his 16th year he had written 14 bi-weekly essay letters to the editor, repleat with references. to the classics, under the pseudonym of Mrs. Silence *Did Jefferson get "Nature's God" for the Declaration from Polly Baker?

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Dogood, that had most of the tongues in Boston wagging. They never did guess he wasn't a widow. He finally told them. For his idle hour reading he studied navigation mathematics, "On Human Understanding" by J ohn Locke and "The Art of Thinking" by Royal, and learned later French, Spanish and Italian. In this . period he set himself the impossible goal of human perfection. To achieve this Olympian state he drew up a list of 12 virtues, intending to concentrate on one each week. He showed his list to a Quaker friend who studied it and then observed in a kindly voice, "Benjamin, you have left out the virtue that you need most to practice. You are a man of very great pride. Your pride shows in conversation. You are not content to be in the right but are overbearing and somewhat insolent. You would greatly benefit from practicing humility". Thus humility became number 13 of his virtues-the one he probably worked the hardest for, in spite of which he would later say, "I cannot boast of much success in the reality of this virtue but I had a good deal with regard to th~ appearance of it."

In his autobiography he wrote, "While I was intent on improving my language, I met an English grammar (which contained) a specimen of a dispute in the Socratic method. I was charmed with it, adopted it, dropt my abrupt contradiction and positive argumentation, and put on the humble inquirer and doubter." He then tells how he abused the method using it to entrap people in their own logic but "gradually", he says, "I left it, retaining only the h<;·, ·. :>f expressing myself in terms of modest diffidence, never using, wb:::•'l l advanced anything that may possibly be disputed, the words cert:unly, undoubtedly, or any others that give the air of positiveness to an opinion; but rather say, I conceive or apprehend a thing to be so and so; it appears to me, or I should think it so and so." Here.\.:then, is his greatest discovery- the subjunctive mood, the conditional, the contingent, the possible. It was the conditional that caught the Assembly and made possible the first hospital in America. Even his profoundest observations on electricity he prefaced with, "Possibly they may not be new to you, as among the members (of the R9yal Society) daily employed in those experiments on your side of the water, 'tis probable someone or other has hit on the same observation".

With his subjunctive he would promote the general welfare, join the giants of science, stand before kings, sway parliaments, create allies for his beloved country, and make love a la Plato to both talent and beauty.

Franklin was a man who knew how to live, and after all, isn't that what preventive medicine is about?

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A MEDICAL SCHOOL SAFARI IN WEST EQUATORIAL AFRICA FOR A HEALTHY "EMERGING NATION"

I have j ust returned from five years of institution building in Nigeria. Not that I built the kind of institution that is "the lengthened shadow of a man," but I did my bit along with many others to create that critical academic mass capable of self-sustained reaction. This is the only kind of contribution in a less developed country that can bring with it a satisfying feeling that the jungle has been pushed back permanently on your little front.

When the violent epidemic of nationitis hit Africa in the late '50s and early '60s, tropical Africa had one world market medical school, a branch of London University in Ibadan, Nigeria (established in 1948).

Someone has said that each new African nation must have an intei:national airline, a TV station and a medical school before it feels like a full-fledged member of the fraternity of modern nations. Nigeria h ad to go a step beyond that. No doubt, because of her size (one-fifth of all Africans live in Nigeria), she felt that she had to immediately have more than one medical school. Thus, independence in 1962 was celebrated with establishment of the School (now College) of :\fed icine as an autonomous unit of the yet-to-be established University of Lagos.

Three Nigerian doctors had hatched the plan for a second medical school: Dr. M. A. Majekodunmi, federal minister of health; Dr. H. 0.

Thomas, dean-to-be; and Dr. Felix Dosekun, vice-dean-to-be. They toured the United Kingdom, Canada, and the U.S. seeking technical assistance to start the faculty. All three had been exposed to the United Kingdo m's best training in their student years. Their goal was a faculty and student body of world market quality.

In the U.S., through the assistance of Dr. Van Zyle Hyde of the Association of American Medical Colleges and through the Commonwealth Fund, they established a working relationship with the University of Rochester in physiology, medicine and surgery. But Dean Note: Bob and Helen Wriglu spentjivt )'tar.( in Lagos, Nigeria,jrom 1963 to 1968. As part of johns Hopkins international program, he helped to e.itablish th.e new University oj Lagos Medical School and was chairman oj th.e Depan:ment of Community Health. He wrote oj his experiences for th.e Wiiconsin Medical Alumni Qtw.rterly (Vol. 9, No. 2, Spring, 1969), and th.e article is reproduced hert' with pennitrion.

:-:?2

Thomas was unable to get help in one of the areas he considered vital in the training of doctors in a grossly underdoctored country - social and preventive medicine. The dean at Rochester suggested that Dr. Thomas try the Johns Hopkins School of Hygiene and Public Health for assistance because schools of public health have far greater strength and depth than departments of preventive medicine in medical schools.

They also would be more able to send a faculty member for a long period of time. At that moment, the stars were in favorable conjunction for Hopkins was seeking an interested African country in which to do a health manpower study, and a UW alumnus named Wright, who was about to retire from the Public Health Service, had been looking for a foreign assignment for IO years (wanderlust?). I had already pioneered a department of social and environmental medicine at the University of Virginia, so l joined the Hopkins Department of International Health on Nov. l, 1963, and departed for Lagos one month later.

A LAND OF 60 MILLION If any reader is as ignorant of Nigeria today as I was then, he thinks of Nigeria as an amorphous glob of rain forest, pock-marked with isolated clearings tenuously connected by trails with just enough Land-rover roads to maintain Her Majesty's presence throughout that glob. What a shock, then, to fly over a modern harbor and business district dominated by a 21-story skyscraper in a metropolitan area of a million people - the capital of a country of 60 million. The vast majority live within 15 miles of an all-season motor road or Nigeria's 3,000 miles of railroad; a country where "the iron grid" of English law through the English language reaches to every nook and cranny of its 356,000 square miles - well, almost; a country where missions had created 10,000 mission schools, had trained the largest educated elite in tropical Africa, and had established the region's largest medical apparatus.

Originally, all the population of Lagos, the capital, was on Lagos Island. Now three-fourths of the population of metropolitan Lagos lives on the adjoining mainland where the college of medicine and university are located.

The teaching hospital was originally conceived as the mainland general hospital but in the minds of the health minister and his two colleagues it became the teaching hospital before it was opened in 196 l. What we found on arrival was a compound of more than 100 acres with a 350-bed hospital built to last a hundred years and faculty housing as solid - basically concrete from the ground to the transite roof, with parquet mahogany floors and air-conditioned bedrooms.

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However, there were no screens in a land where malaria is holoendemic.

My job was to start a Department of Preventive Medicine, only here it would be called ''The Department of Community Health" to give emphasis to community and healJh. in contrast to individual and disease. I had arrived in the second year of a five-year curriculum. My dep artment consisted of myself, a Nigerian steno-secretary, and leave to find two assistants if I could. I had already decided what my research areas would be - one, health manpower, description and functional analysis; two, population. At the outset my teaching approach had to be based upon my previous experience until I could find out what my 28 African students wanted to know.

FIGHT FOR A PLACE IN THE SUN Most of my energies in the first year went into a fight for a place in the sun, for time in the curriculum, and first class citizenship for community health in a faculty only a little more sympathetic to the oneto-many aspects of medicine than is the average medical faculty in the V.S: and U.K. Without the intellectual commitment of the dean this would be a different story. Trying to get a medical faculty dominated

by British traditions to structure a curriculum in terms of stated objectives is no easier in Nigeria than Dr. Ham found it at Western Reserve.

First, I know from experience that brainwashing begins early in medical school, that the .silent language of status tells a student how important a subject is by the amount of time it is given in the curriculum, the place of the time in the curriculum, the power of its exams to bar advancement, the size of the staff, the extent and adequacy of the quarters. All this preceeds any judgment of individual quality.

By the end of the next year I was still in two rooms (strategically located next door to the dean) and had found my deputy, Dr. Adeniyi Adeniyi-Jones. T hrough endless faculty sessions and committee meetings, the Department of Community Health had achieved teaching time in all five years, designation as both a basic science and clinical department with bar examinations at the end of the third year and at the final, and an agreement to keep the pattern unchanged for five years.

program in collaboration with the Lagos health officer who had funded family planning in Nigeria. We obtained private funds (Unitarian Service Committee) to permit his newly created Fa:mily Planning Council to begin a network of clinics, which we could use for teaching purposes pending creation of our own departmental clinic. w~ .also began negotiations with the Ford Foundation for a $380,000, threeyear grant to create a "community laboratory" for the study of population d ynamics and related problems, and for the construction and operation of a family planning clinic. As the first year was waning my deputy Dr. A. Adeniyi-Jones, and I began to crystallize our curriculum for the five years.

In the minds of most U.S. students preventive medicine is mostly a chore - not a core -subject. For many, a medical Shakespeare would no doubt put it among the tedious things of life along with "the law's delays, a tired horse, a smokey chimney, a railing wife." A few years ago a. sample survey of graduating medical students in the U.S. failed to uncover a single student who planned to make a career in public health. After five year.s' exposure to our own brand of community health teaching, six of 28 Nigerian students applied for fellowships to get m asters'. degrees in public health.

"YOU START WHERE THEY ARE" In shaping our curriculum we followed the health educator's axiom.

"You start where they are." To find out where the students were in their thinking, we first gave as assignment upon entering medical school a questionnaire and a request for a two-page essay on what they thought would be a typical 24-hour day in their lives five years after completing medical education and training. Ninety percent said they were going on to be specialists (none in public health); 75% were going to practice in cities of 50,000 or more. All but one expected to have his professional base in a hospital, where 75% expected to be doing some kind of surgery. Over a three-year period of testing the entering students these figures changed but little except that after the first. year of the questionnaire a few did opt for public health on admission.

These findings were no surprise. In fact, they were little different than one would expect in the U.S. Accordingly,. we proceeded to structure the curriculum to accept these basic student assumptions and to attempt gradually to widen their horizon to include the group in their medical thinking.

While all of this was going on, our first step to implement a program . of population activities was begun. This was to be a two-pronged 24

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We started the first term of the first year with an "introduction to the art of medicine" in which the cJinical departments presented a case

carefully chosen to illustrate a community health problem in an individual disease. For example, from surgery we had an accidental burn or vehicular trauma; from pediatrics a case of (\Spiration pneumonia due to force-feeding, or tuberculosis caught from the mother; from obstetrics and gynecology a multigravida family planning failure with complications; etc. These case presentations were alternated with sessions on types of medical practice, medical ethics, and problems of medical care. The sessions were jammed by synthesishungry students who were living on a diet of dissection. No need for roll call.

Special attention is given to the use of auxiliaries and regionalization of medical services and facilities to ensure that every health problem is resolved at the lowest level of complexity compatible with reasonable standards 9f care and safety. In a country with one doctor to 40,000 people, it is madness to train doctors to believe only they can diagnose and treat every sniffle. It is not only madness, it is the sure road to professional ennui and cynicism. In the public clinics of Lagos, doctors average 90 seconds per patient, hour after hour, day after day. We know from controlled observation that about 90% of these cases are minor enough to be handled by a nurse. Who can maintain an interest in high level practice on a diet o f 90% trivia and I 0% meat with no time to chew the meat?

In the second term of year one, a medical sociologist in the department organized a course on "structure and function of the Nigerian family in health and disease." Here the student was introduced to population dynamics and family planning. In the third term of the first year, students visited selected families in their homes for a sociological and environmental assessment.

Our fourth year teaching program is integrated with pediatrics.

Students work up patients on the wards in the mornings and visit a selection of their discharged patients in their homes during the afternoons. The visits are made in the company of a public health nurse and a student nurse.

At every step a!l members of the departme!1t used every opportunity to relate the teaching to the practice of medicine as a student dreams¡ it.

If you ask a Lagos medical student how you would go about uncovering cases of tuberculosis in a Nigerian town, he will not (if he follows the teaching!) start off with a recommendation to do a tuberculin and x-ray survey. H e will start off with a recommendation to get the doctor in the area to do a Ziehl-Neelsen smear on every patient who comes to .his office with a chronic cough and sputum, citing Banerji's work in India.

seminar.

Students then lead a discussion of their cases before a weekly

GEARED TOWARDS THE FAMILY In the second year, stud ents get in introduction to epidemiology, a course in applied medical statistics, and a course in environmental health problems in the tropics. Even our Nigerian doctor of public health engineering gears his illustrations .and questions to the family: typical discussion question - "lf'we eradicate malaria, what will it do to family size?" Students make the usual field trips in the second year to see sanitation and.pollution in action.

The major third year thrust is studying the ways Nigeria and other countries organize medical services to improve quality and distribution.

Health manpower, institutions, and their relationships in Nigeria are studied. Medical care systems in the United States, United Kingdom, U.S.S.R., Sweden and Peru are studied. Students make field trips to representative institutions and organizations.

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COFFEE MACHINE COULDN'T KEEP UP In the fifth year, the students have a four-week community clerkship at provincial hospitals and clinics. In addition, they investigate a problem of their choice and make a written repon at the end of the clerkship. This is a popular experience. It is still in the development stage. Ideally, we want eventually to develop a formal relationship with selected field stations where the doctor in charge will have a university position as field professor, somewhat along the lines Wisconsin has followed for so many years.

As one year dissolved into another and our teaching program took shape, our staff enlarged, our Ford grant came through, a new building rose at the end of a long hospital corridor. In the building was a family planning clinic and a data processing laboratory with the usual gadgets of the cornputer age, an environmental and occupational health laboratory, offices, seminar and library rooms, and a 50-cup coffee machine too small to serve all 71 employees of the department at one time.

Now we are entering a new phase. Our basic goal in community health is to keep man in balance with his environment. Through untold

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centuries of adaptation, the African tribesman had accomplished this, in spite of primitive agriculture, through high birth rates and high death rates - especially among the "under fives,., where mortality equals 400 to 500 per thousand live births. Only a little modern technology is needed to destroy the balance. To help maintain this balance in the interests of optimum improvement in the level of living, we see our major challenge in community health to be. child saving and 路child spaong.

To this路 end we are negotiating a substantial training grant from US/AID to set in motion a train of forces that will pull the nurse and midwife into a new orbit of responsibility fu,r primary decision-making in the care of the mother and the young child. We already have the pilot study to prove it works. These findings are to be published in the near future. We also know that mothers and fathers of live children are more interested in family planning than mothers and fathers of dead children. Paradoxically, it is necessary to increase the growth rate of a population in order to decrease the rate of increase (without resort to the Four Horsemen).

Nigerians than their colleagues who attend the best schools in the U.S. or the U .K. They have concentrated on the problems of keeping people alive long enough to reach the wearing-out stage, while their foreign-trained colleagues have been spending untold hours learning the nuances of degeneration.

At the beginning of the 1968-69 academic year, Lagos College of Medicine had a faculty of 81, of whom 80% were Africans. Seven of the eleven departments were headed by Nigerians. The class of '73 consists of 53 first year students. The class of '74 is expected to reach I 00. A viable institution has been born.

Our association with the Lagos College of Medicine is open-ended.

At the moment I have four former students from my classes in Lagos in my Master of Public Health classes at J ohns Hopkins and more are on the way.

Probably the greatest impediment to the development of rational medical education in the less developed countries is the tendency of doctors everywhere to so admire their own pattern of medical knowledge that they think it is good for anybody. What is excellent medicine 路 in the U.S. can be immoral and medical malpractice in a country with one doctor to 40,000 people and a per capita income of less than $100. Nigerian needs call for a maximum of preventive action by every physician and maximum use of auxiliaries to assure that doctors handle only the tough cases. (Might be worth a try right here!)

CORONARIES ARE RARE The bulk of medical problems are infections and malnutrition due to faulty environment and knowledge. Pneumonia, neo-natal tetanus and dysentery are high in the lists of causes of death. All children get malaria. Most go through protein-calorie malnutrition at weaning. Add to that upper respiratory infections, measles or dysentery and you have another young candidate for immortality. On the other hand, I didn't see a single coronary in the .teaching hospital for a year. The first one was the WASP director of our Anglo-American Chorus, an embassy employee!.

In conclusion, we feel that students who graduate from a Nigerian medical school are better equipped to meet the current 路health needs of

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29

TEACHING COMMUNITY MEDICINE IN MEDICAL SCHOOLS THE PROCESS-PRODU CT DILEMMA

To a very considerable. degree, as teachers of Community Medicine, we have been failures. We have neither been able to define or foretell the full force of prevention nor to interest more than a handfull of medical students in our specialty. No doubt we have shared the propensity of all specialties to teach as if we were trying to capture as many students as possible for our particular specialty rather than to infuse into the students' own plans that part of our specialty that they can and will use. In Community Medicine to aim at the first goal makes possible a major contribution to the practice of a small fraction of the students we teach, and probably irritation for: the majority. The second goal holds the hope of influencing all to incorporate some Community Medicine into their practices and to beguile even more than before into our specialty.

For a dozen decades we have proceeded on the premise that o~r goal was to increase and equalize life expectancy, or as Smille observed, "to increase the rate of coronary occlusion," only to be suddenly slap ped in the face with the fact that our goal should have been to put man in balance with his environment. If only we had suggested it instead of a preacher or if only we had believed it after he guessed it. But even at this late date some medical schools, and at least one school of -public health, are not among the true believers.

In the teaching of Community Medicine our first failure was in strategy. Our second failure .h as been in tactics. Through the years we have been trying to figure out ways to interest the average medical student in the group aspects of health problems by contemplating our academic navel when we should have been consulting the novitiates. In the U.S., and elsewhere, the countercultural revolution has shocked many a professor with the pedagogical slogan being heard with ever increasing frequency (and stridency), "T each us what we want to know." This Revolt of Youth, of course, is not new. In the early 1300's Padu a, the foremost medical school of Europe, flourished as a cooperative venture between the students and the professors in which the profe.ssors taught the students what they wanted to know-- or Note: Bob Wright's favorite course in the Departmem of lnternalUmal Heallh at johns Hopkins was IH-9, Teaching and Learning of Community Health. This piece included in the Resource Maurials for the course in the early I970's is reproduced here.

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else. A century ago, the great Froebel said, "All learning should be pleasurable," which is not possible for those who are learning something they do not want to know. In this century, Alfred North Whitehead pointed out in his "Aims of Education" that the initial phase of learning is characterized by a romantic attitude toward the subject matter and that this attitude must run its course before the student can develop the "precision" necessary for the assimilation and organization of knowledge. The conditions for learning, says Whitehead, require that the learner have an active, not passive, attitude, that he set high standards for himself, that he learn at his own pace, and that instruction be problem-oriented to instill the spirit of inquiry. When we introduce the student to the study of medicine through a nauseating feast of basic science and statistics with its intense inculcation of the scientific method we stifle his romantic fantasies and with them his motirntion for learning. Kahlil Gibran in "The Prophet" puts it most beautifully, "No man can reveal to you aught but that which already lies half asleep in the dawning of your knowledge. If he is indeed wise he does not bid you enter the house of his wisdom, but rather leads you to the threshold of your own mind."

Reports out of China indicate that the student pressures and the Cultural Revolution are producing a turnabout in medical education similar to that suggested by Strassman, Taylor and Coles in their call for a new a pproach to medical education. Instead of introducing the student to medicine via two denaturing years of basic science the Chinese are having him don a white coat, or a surgical gown, put a stethoscope around his neck and an otoscope in his pocket and begin seeing patients. At first blush it sounds anathematic, but is it really? In other times, as we all know, thousands of doctors learned medicine that way. A neophyte in a white coat is not necessarily in the decisionmaking process-learning what he wants to know while we are in a position co beguile him painlessly into that position of precision where assimilation and organization of knowledge can occur.

Preventive medicine teaching needs to learn these truths about students even more than the rest of the curriculum because the fantasies about the ills of the group are infinitesimal compared to the fantasies about the ills of the individual. Prospective medical students seldom have a fantasy about peopl.e. T heir fantasies are about a man, a woman, a child. When I was at the University of Lagos College of Medicine we got the students in the Department of Community Health the first week they entered the school. Their first assignment was to fill out a short questionnaire and to write a two-page description of "This is my life as a doctor." They were to envisage themselves five years after they had completed all their formal training. The description

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begins when the bedside alarm rings in the morning and ends when the alarm rings the following morning. They were to describe all their imagined actions in those 24 hours.

The composite picture of the doctor-life entering students brought to the Lagos College of Medicine was with little variation something like this: I rise, pray, bathe,·hreakfast and rush to the hospital where I take a quick look at the patients I operated on the day before, give precise orders to the nurses, rush to O.P.D. to select the patients for surgery, clear out the rest as quickly as possible, operate, make rounds, give more orders, go home for a reading session with the journals, exercise, socialize, and be ever alert for an emergency call. In three successive classes only one student emphasized an office practice and one student, praise the Lord, said he expected to be a health officer. Our finding fully confirmed the observation of Dr. Duncan Clark that, "One must note the great enthusiasm of th·e student for curative medicine."

If we are to follow the dictum of the educator to "start where they are," we must start with patients not people. If we would hold the attention of the students, we must be as persistent about patients as Cato was about Carthage. For too long preventive medicine has tried the other tack and as Dr. Brown said, "With certain exceptions, efforts to effectively bring the subject (of preventive medicine) into the mainline of the medical. curriculum have made little impression on medical education throughout the world." At Lagos we made a modest beginning to try to teach the student what he wants to know, by starting where the student is, through an "Introduction to the Art of Medicine" with the clinical departments providing patient demonstration selected to permit emphasis on group implication of indiv.idual illness.

Throughout the five years, culminating in the Community Doctor Clerkship, this emphasis on group aspects of individual illness was maintained. One indication that this approach has had some success with Lagos students is the fact that 6 out of the first 28 graduates (at the end of their internship) applied for fellowships to study for the M.P.H. Within three years 9 of 28 had decided on careers in Community Medicine.

skills and attitudes that a physican must possess to practice modern medicine properly. These observations are all about individual patient care. The closest they come to community (social) medicine is to state that, "The Government is also asking the doctor's to be leaders in improving the delivery and health care to all the people." You will note that the students did not say doctors ought to do it, only that the government is asking-and in the U.S. there is a palpable difference between the two positions.

With the increased emphasis on elective-time-plus-a-medical-corecurriculum in more and more medical schools, preventive meflicine must face up to the. difficulty, if not impossibility, of being comprehensive. Actually, this. point has long since passed. ~The First World Conference on Medical Education iii 1953 stated the medical curriculum "should be concerned, not with presenting m~ses of factual data, but with indi<;ating the scope, potentialities, duties and respop.sibilities of medicine, both curative and preventive..." The report is repleat with encomiums to medicine as a socal science and the intensification of training in preventive medicine.

In much of the U.S. preventive medicine still is not in the mainline of the medical curriculum-at least from the student point of view.

In the November, 1969, issue· of the Journal of Medical Education, J. R. Martin, a recent graduate, reports on "The Crisis in American Medical Education: The Student Point of View." The · Standing Committee on Medical Education of the House of Delegates of the Student American Medical Association listed eight observations on

If faculties ever got the rµessage from that 1953 Congress, something peculiar must have happened on the way. to the academic for:um. The U.S. students on the curriculum committee of their national organization did not get the message from their professors sufficiently to mention preventive medicine among "the skills and attitudes a physician must possess to practice 1970 medicine properly." At a recent annual meeting of the U.S. Association of the Teachers of Preventive Medicine one speaker stated without challenge that we had failed to reach the interests of medical students with the two basic disciplines of community medicine, biostatiStics an~ epidemiology. Perhaps we should not feel defensive about biostatistics. Medical students are usually interested in things bio-but it must be a rare medical student who has a fantasy in statiStical symbols. If as a faculty of medicine we are going to insist on a knowledge of statistical theory and practice by our students, it should be learned in neutral territory or be a prerequisite to the student of medicine. This may be hearsay, but I am not at all convinced that men and women are. better doctors because "they once had to learn, and have now long forgotten how to do a ChiSquare, a standard error of the difference, or a coefficient of correlation-not to mention the more sophisticated manipulations.

Neither am I convinced that he must learn these to be an intelligent participant in practical epidemiology. Long ago John Snow demonstrated that good epidemiology had more to do .with shoe leather ·than it has with calculators. Many an American citizen is as conversant with epidemiology as his doct0r through the fascinating disease detecting

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stories that he reads in the New Yorker magazine over the by-line of Berton Roueche. At least one school of public health uses Roueche's collection of these stories, "Eleven Blue Men," as one of its texts in the course in epidemiology. We used it successfully at Lagos. When I suggested to one of my colleagues that "Eleven Blue Men" be used as a text for introducing epidemiology to medical students he objected on the ground that it would not be possible to teach the subject in a comprehensive manner with such a text. This poses to teachers of preventive medicine a crucial question: Is it better to attempt to present a subject in a comprehensive manner even though the great majority of the class are turned off from the subject for all time or to titillate the interests of the great majority with a few fascinating examples of what the epidemiological method can do and leave them with the feeling that they would like to learn more?

In this era of information explosion it is not possible to be comprehensive, in any event. Only those who positively choose a subject for their major interest can even come close. In the U.S. we are moving rapidly into an era of elective studies in medical school. T oday our med.ical schools have from I 0% to as much as 46% elective time in the total curriculum. In such a frame we can expect specialty polarization to come early and strong. In such a frame it is masochism to try to make a junior health officer out of every student through time honored visits to water and sewage plants, dairies, bakeries, et cetera, et cetera, when sound-on film can bring all but their smell into the class room.

coordinating and in certain instances integrating the prevention concerns of active departments in that school" in the medical student teaching program. This alliance offers the generative possibility of continually infusing a clinically based and individually oriented program with the newest and most urgent group considerations of health care appropriate to the education of the practitioner. Only time will tell whether this approach is more successful than its predecessors in beguiling the student to a more rational balance of concern for the needs of the individual and the group. If such a two-horned approach is successful, it could be used by medical schools without a School of Hygiene affiliation where sufficient commitment and finanicing are available for equal development of both parts.

Students are changing. Many more than previously are showing a sincere interest in at least one aspect of Community Medicine, the distribution of health services. Some might question whether this is a preventive medicine interest since it is so heavily polarized on patients.

Perhaps it is but a recrudescence of J udeo-Christian concern for the sick.

In any event (to paraphrase Malthus), the passion for individual medicine is necessary and will remain nearly in its present. state with the overwhelming iI?-terest of the average medical student continuing to focus on the individual patient who has a present or potential medical problem. If we are to reach budding doctors ¡with the needs of the group, it is we who must change even more than the students.

For the many who come to scoff we must teach about group needs through individual apprehensions; and for the few who remain co pray we can teach through all those delicious group-centered techniques that titillate the Community :Medicine professor's fancies.

The University of Toronto has announced it is about to approach the dilemma of patient-centered student interests and group needs through a plan that ministers to both horns. They are proposing to base their program in the Department of Medicine, thus establishing preventive (community) medicine in the mainstream of student interests. The Chairman of the Department will be assisted by two or three full-time staff who will serve primarily the Faculty of Medicine with responsibility for incorporating through the Medical Faculty's regular teaching staff the idea of prevention in all its aspects into the system-teaching of the undergraduate and into the postgraduate clinical program. This clinical component will have a full-time counterpart in the School of Hygiene, who will be "the focal point for

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CURRICULUM VITAE ROBERT D. WRIGHT, M.D. Personal Information: Date of Birth: March 30, 1909 Place of. Birth: Menasha, Wisconsin Religion: Unitarian Marital Status: Married, three daughters Date of Death: April 16, 1981

Education: 1923-27 West High School, Green Bay, Wisconsin 1928-33 BA in Medical Science, MA in Medical Science, University of Wisconsin 1933-35 MD, Washington University, St. Louis, Missouri 1935-~6 General Internship, St. Louis City Hospital 1936-37 Residency in Obstetrics and Gynecology, St. Louis Maternity Hospital Public Health Administration, Vanderbilt University 1937 1939-40 MPH, Johns Hopkins School of H ygiene and Public Health 1950 Certified in Preventive Medicine and Public Health 1972 Phi Beta Kappa, Johns Hopkins University Professional Experience: 1937 Acting Venereal Disease Control Officer, Missouri State Board of Health (Organizing administrative procedures) Health Officer, Poplar Bluffs, Missouri 19.37 (Communicable disease activities) 1937-38 District Health Officer, Osceola, Missouri 1938-63 Commissioned Medical Officer, United States Public Health Service 1939-40 Student at Johns Hopkins School of H ygiene and Public Health in public health administration and venereal disease control 1940-41 Director, Mobile Clinic Demonstration, Brunswick, Georgia (3 counties in Southeast Georgia) 1941-43 Venereal Disease Consultant, North Carolina Department of Health (113 clinics, budget of $550,000)

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1944-45 Medical Officer in Charge, Kanawha Valley Medical Center, Charleston, West Virginia (Organizing and directing rapid treatment hospital with 250 beds, 90 employees and 500 patients/month) 1946-50 Assistant Director and Associate Director of Venereal Disease Research Laboratory, Staten Island, New York (Clinical and laboratory research in penicillin treaonent of syphilis and gonorrhea) 1950-51 Director of Research and Professional Education for Venereal Disease Division, United States Public Health Service, Washington, D.C. 1951-56 Professor & Chairman, Deparonent of Social and EnVironmental Medicine, University of Virginia Charlottesville, Virginia 1956-59 General Health Consttltant and Deputy Regional Health Director, Region 3, United States Public Health Service. (Consultation to states on Public Health Administration and Civil Defense): Clinical Professor of Preventive Medicine, University of Virginia 1959-61 Assistant Director, Office of Vocational Reh~ilitation; Clinical Professor of Preventive Medicine, University of Virginia 1962 Medical Consultant, Division of International Health, Special Studies, United States Public Health Service; Clinical Professor of Preventive Medicine, University of Virginia 1963-68 Professor, Department of International Health, Johns Hopkins School of Hygiene and Public H ealth. (Consultative work for the then new University of Lagos School of Medicine, Nigeria, as Chairman of Deparonent of Community Health) 1968-79 Professor, Department of International Health, Johns Hopkins School of Hygiene and Public Health; Co-Director and .Instructor in IH-9, Teaching and Learning of Community Health 1979 Professor Emeritus, J ohns Hopkins School of 'H ygiene and Public Health Other Activities: American Board of Preventive Medicine and Public Health (Diplomate) American Men o'r Science Who's Who in America American Medical Association (Member) 37

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American Public Health Association (Fellow) American Venereal Disease Association (Member) American College of Preventive Medicine (Fellow) Royal Health Society of Great Britain (Member) Albemarle County Medical Society (Member) Health Council, Charlottesville, Virginia (~mber 1951-5 7) J oint Board of Health, Charlottesville-Albemarle County (Member 195 1-5 7) Visiting Nurse Association (President and Board Member, 1951-56) Fact Finding Commission, Virginia Tuberculosis Association (Member) Board of Directors, Virginia TB Association (Member 1955-59) Virginia Council on Health and Medical Care (Member) Publications: More than 30 articles in national and state medical journals.

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