Medical Education in Saudi Arabia SAUDI ARABIA is rapidly changing as the wealth derived from its oil is used to develop a modern state. It is largely mountain plateau and desert with little rain except along coastal strips. Most of the country is plagued with dust storms. Oil is found largely on the east coast. Jeddah on the west coast is the traditional seaport and point of entry for the more than a million pilgrims each year on the 1month hajj to Mecca. Though foreign embassies remain in Jeddah, the capital is Riyadh in the central region. Most of the country lacks adequate water supplies. The rapid growth of urban areas has far outstripped utility systems, especially sewage disposal. Water is delivered to many homes by tank truck or donkey cart. Desalination plants cannot meet the demand for central systems. Deep wells serve the nomads. Where rain falls, supplemented by irrigation, water stands and harbors snails. Much food is imported, some frozen and some dehydrated for reconstitution. The electrical network is more widespread than water and sewer lines, but voltage is erratic and power failures frequent. Construction is hectic in cities, automobiles are increasing in numbers, huge trucks and heavy machinery are everywhere. Seaports lack docks to unload purchases from abroad and ships may wait months. The Kingdom of Saudi Arabia is an absolute monarchy. The royal family is large and has many able members educated abroad, many with doctorates. National pride is high, and almost all students abroad return. Family ties are strong. Life for the Beduin nomads has changed little for centuries. Saudis are independent and do not like to work with their hands for others. Manual laborers, domestic servants, and professionals such as nurses, technicians, and doctors are imported mostly from other Arabic-speaking nations—Egypt, Pakistan, Yemen. The role of women is slowly changing. They remain in the home, do not drive cars, rarely work outside. Native dress with veil is still worn. Few women travel. National policy decrees segregated facilities for the education of women at all levels. Girls are taught by women; if men lecture to them it is by television. Delivery of health care is hampered by restrictions on the use of Saudi women in nursing both sexes. Some go abroad for education in medicine and dentistry and return to practice in cities, but the number is very small. Alcohol is strictly forbidden, and foreigners may not bring it in. Cigarette smoking is widespread. Daily prayers are widely observed in business and public institutions. Education, even in science, is in Arabic through the general university level. English is taught in secondary schools, but recent tests on entering medical and engineering students indicate comprehension is only 3 0 % . Texts used in these professional fields are in English. Of graduates taking the secondary-school science track, 40% prefer medicine and engineering. An excellent university oriented toward petroleum, minerals, and engineering is in the Dhahran area. General universities have recently been established in Riyadh, Jeddah, and Dammam with priorities for teachers, physicians, and engineers in that order. Medical schools have been started in these three and will restrict admission to Saudis for 10 years. For each

year of support, students are required to return 1 year of service in a government institution, where most medical care is delivered. Private practice is minimal at present. The major health problems are trauma (largely from automobiles), gastrointestinal infections by bacteria and parasites, bacterial pulmonary and urinary infections, tuberculosis, and chronic obstructive pulmonary disease (probably from dust), with schistosomiasis and malaria in certain coastal areas. Trachoma is under control in urban areas. Venereal disease, diphtheria, and meningitis have a low reported incidence. Poliomyelitis and other viral diseases are common in villages and nomadic tribes. In the east, 40% of the population have been found to have sickle-cell trait. The pilgrims bring cholera and meningitis with the possibility of reinfection of the population with various other agents; this problem seems reasonably well controlled considering the magnitude of the hajj and the diverse regions of the world from which pilgrims come. Mental illness, heart disease, and, in the older group, cancer are increasing. The major health goals are to reduce accidents (which are the largest current cause of death) and infant mortality, to improve nutrition and sanitation, and to reduce environmental hazards. Emphasis will be on prevention, including widespread immunization, rather than curative medicine, for the next decade. Facilities to achieve these goals are limited. Hospitals largely are outdated in design, greatly overcrowded and understaffed, and lack trained maintenance personnel for equipment and building services. Exceptions are the new memorial hospital to King Faisal, small military hospitals and clinics run on contract by U.S. personnel, and those associated with the oil company (Aramco). Hospitals are only beginning to get modern laboratory equipment. Ambulatory care facilities are inadequate and largely connected with hospitals. Currently more than 60 lay hospital administrators are being trained in the United States to replace physicians. About 40 scarce Saudi doctors are in various administrative positions. All levels of health personnel are in extremely short supply and are located in cities. Most come from outside the country on l-to-3-year contracts, so turnover in staff of hospitals and professional schools is frequent. "Drug stores" may be run by anyone and sell most drugs over the counter. "Pharmacies" are fewer, are run by graduate pharmacists, and fill prescriptions with strict control of narcotics. Many people approach the pharmacist, describe symptoms, and are sold drugs. Some folk medicine is practiced. The educational programs in medicine are just beginning. The first school was opened in Riyadh in 1969 and will graduate 22 men in 1976. The 70 women are only in first- and second-year classes at present. Plans are to admit 75 men and 35 women in 1976, with women taught several miles away. This pattern will continue for 10 years even in new permanent facilities for the basic sciences. Both sexes ultimately are expected to be taught in the same clinical facilities in segregated classes at first. In the early classes more women than men have dropped out, but for personal not academic reasons. The main library is at the men's campus with a small one at the women's. Abroad

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Some medical faculty feel a school of public health should be established now. A 4-year Bachelor of Science program in pharmacy has been taught in Arabic for years. Dentistry is in the planning stage and will admit only men for the foreseeable future. Women will become hygienists. Basic sciences will be taught by a separate faculty with content less for dental than for medical students. Faculty have discussed the need for ambulatory care facilities for medical teaching, possibly mobile units. The curriculum is based on the British system of 6 years after secondary school, with external examiners. The director of the teaching hospital is also dean for a projected faculty of nursing. He plans a 4-year university program in nursing science and hopes the first 2 years will have students taught by medical faculty along with medical students. The new King Faisal Hospital, not used for teaching, has 80 beds open, two hyperbaric chambers, four renal dialysis units, a linear accelerator, large TV studio, and TV monitoring cameras in every room with miniature screens at the hospital switchboard. It is building a cancer research unit with minimal animal facilities and installing a 30-mev cyclotron to produce isotopes. The next school opened was King Adbulaziz University in Jeddah in 1975. The first class of 60 men and 40 women was selected from 200 applicants who had minimal grades of 83 and 86 respectively on a nationally administered secondary school examination. Attrition is high, with as many as 20% failing the first year, chiefly because of difficulty with English. Women, who work harder than men, are taught by eight female faculty in a separate facility but dissect both male and female cadavers. A small secondyear class of students was transferred from the University of Riyadh. Faculty for basic sciences are mostly from abroad on 1-year contracts. Premedical science is taught in Arabic with basic medical sciences taught in English, but progress is slow because of limited comprehension. The quality of work by the students is satisfactory, but they have not been taught to write essays, so examinations are by short question and answer methods. The present basic curriculum is 6 years with the first heavy in English and science, next two preclinical, fourth transitional, and last two clinical. The school is now in temporary facilities. A 1-year internship will follow. It is hoped graduates will be accepted into residencies abroad, chiefly in the United States and the United Kingdom. During a period of years, advice has been sought from a number of consultants including deans of four northern British schools, U.S. faculty from several schools, and single members from other European and Asian schools. The dean sees the mission first to train faculty. The school will accept no responsibility for all aspects of medical care for any geographic area. A teaching hospital is planned to serve initially as a referral facility for the western part of the Kingdom. Satellite ambulatory primary care centers may be used for teaching, but the patient-care responsibility will rest with local physicians, not faculty. Research is planned from the beginning, probably in the form of an institute devoted to local problems needing immediate attention, such as those of the hajj. Currently the Central Hospital is being used. It is old and very crowded, with open wards, one devoted solely to head injuries from automobile accidents. All emergencies in the area are brought there. It has well-equipped four-bed intensive care and two-bed dialysis units. Laboratory equipment is simple and is greatly overloaded. A large outpatient department is operated with poor facilities. The school can use the small 678

Kings Hospital, which has a limited variety of patients but a spacious uncrowded outpatient department. Close to the city is a small military hospital with excellent modern facilities and a very well-equipped laboratory staffed by able U.S., U.K., and Canadian doctors, nurses, and a midwife. It is not used for teaching. Programs in dentistry, nursing, pharmacy, public health, veterinary medicine, and allied health professions are in the discussion stage with a group of U.S. consultants. The last school started was King Faisal University in Dammam. University facilities are scattered across a 20mile area. In 3 weeks in 1975, the school recruited 59 men for a first-year medical class and sent them to the U.S. for premedical science and English training. They will return to Dammam for the second year. Women will be admitted in 1976 but will be taught on a separate campus. The major library, teaching laboratories, and large lecture rooms will be shared at scheduled separate times. No female faculty have been recruited yet. The school is being advised by a group of U.S. consultants. The dean expects about half of the graduates to go into practice with the remainder into government service. The school will emphasize primary ambulatory care in community settings without hospital beds. It is willing to build a rural center up to 100 miles away for training. Islamic culture will be taught and the correlation of basic science with clinical work stressed. No behavioral science is planned as such. The degree will be withheld until after a 1-year internship. The dean believes basic sciences can be taught to all health professionals by medical faculty, though at different depths, the better to train a true health care team. The school has been asked to teach basic sciences for a new school of veterinary medicine, which opened in 1975 but has been able to recruit only five Saudis out of a class of 13 for the first year. At present it is associated with a school of agriculture separated from medical facilities. Nursing is planned as a 3-year program. Those for dentists and technicians are expected to start soon. The school is willing to send prospective medical faculty to the U.S. at full salary for postgraduate training in clinical fields. The Supreme Council of Universities in Riyadh is to coordinate all activities in higher education. It plans to permit each medical school to develop its own flavor and to intervene only when it sees one omitting material or overstepping its role. After 10 years the council will evaluate which program seems best fitted for the Kingdom. As yet it has taken no action on what degree will be awarded or when in relation to an internship. The 2-year community colleges being developed will produce nurses and technicians for medicine and health engineering when they open in 1977 in small towns. They will give associate degrees after 2 years. "Health Institutes" admit students after primary school and are training practical nurses and technical assistants. Coordination with the universities in the major cities will be through the council. Coordination between the three medical school deans is recognized as desirable, but no mechanism for such has yet been set up. The expectations of the universities and government are high, but probably not all can be achieved as conceived. Programs will evolve and change with experience. Some plans may be abandoned. Needs are great, and help from abroad is gratefully accepted. (GEORGE T. HARRELL, M.D., F.A.C.P.; Timonium, Maryland; and Vice President for Medical Sciences Emeritus, The Milton S. Hershey Medical Center, The Pennsylvania State University)

November 1976 • Annals of Internal Medicine • Volume 85 • Number 5

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Medical Education in saudi arabia.

ABROAD Medical Education in Saudi Arabia SAUDI ARABIA is rapidly changing as the wealth derived from its oil is used to develop a modern state. It is...
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