357 TRANSACTIONS
0s THE ROYAL
SOCIETY
ROYAL
OF TROPICAL
SOCIETY
MEDICINE
AND HYGIENE,
OF TROPICAL
Ordinary
VOL.
73, No.
4, 1979
MEDICINE
AND HYGIENE
Meeting
Manson House, Thursday,
19th October,
1978
The President: DR. S. G. BROWNE in the Chair
Symposium The contribution
of medical missionaries to tropical
ServiceStLaini;tw-Fh The Leprosy Study Centre, London
Summary Medical missionaries, historically the pioneers in introducing Western medicine into many tropical countries, are today responsible for a significant proportion of health care in several of those countries. Illustrating his theme with references to personal experiences in the former Belgian Congo, the author enlarges on the organization of a church-related comprehensive health care programme based on a chain of rural health centres and satellite dispensaries that brought curative and preventive medicine to the whole population within the area covered. Trypanosomiasis was eradicated, yaws and tuberculosis controlled, cerebral malaria eliminated, worm-loads reduced and nutrition improved. Leprosy was treated within the integrated service as soon as the sulphones became available. Medical auxiliaries and nurse-midwives were trained practically to tackle the local problems. Students from many missions over a wide area went into government, mission and company employ after training. Research concentrated mainly on the solution of pressing local problems, such as onchocerciasis and leprosy, but incidentally investigated interesting clinical phenomena.
Introduction The Centenary of the Medical Missionary Association provides a fitting opportunity not only to pay tribute to a worthy succession of medical missionaries whose training was made possible or facilitated by the Association, but also to glance at the significant contribution made in the past by medical missionaries to the health services in many tropical countries. In the pioneering past, medical missions have noticeably been active; but also today, in some countries, services provided by Christian organizations may account for a quarter of all the health services available, whatever the yardstick employed-doctors and nurses, hospital beds, operations, consultations. With the passing years, as Sir Clement Chesterman has shown in his paper, the emphases may have changed, and the relative importance of medical missions may have diminished as governments have rightly assumed more
medicine
responsibility for the health of their peoples; but their contribution in service, training and research has frequently been of crucial importance in the develooment of the health services. The obvious and acknowledged part they have played has been matched by their catalytic influence on the quality of medical care, supplemented as it has been by the parallel growth of official medical services introduced by the colonial regimes that it is now unfortunately fashionable in some quarters to denigrate. It was my good fortune in 1936 to follow in the footsteps of Doctor (now Sir Clement) Chesterman at Yakusu, and, with my honoured colleagues Raymond Holmes and a team of English nursing sisters attached to the Baptist Missionary Society, to develop a programme of comprehensive health care in an area of some ten thousand square miles in the Oriental Province of the former Belgian Conao. In many ways this service was not typic2 of the average mission hospital of that epoch, but the ideals of community health care embodied and exemplified in the programme have more recently become accepted as the norm for such organizations integrated into government health services. The initiative and flexibility characteristic of many nongovernmental organizations can make a real and lasting contribution to health and serve as an example to official medical services. The Service Component In the 20s and early 3Os, the scene was dominated by the sheer medical needs of the river- and forestdwellers many of whom recalled the horrors of the slave-trade and who were now confronted by an epidemic of trypanosomiasis (CHESTERMAN, 1932) superimposed on holoendemic malaria and endemic yaws. It was the opportunity provided by those medical challenges that assured a genuine welcome for Western curative medicine. “The needle”. which introduced parenterally such effective medication as suramin, quinine and neosalvarsan, was the instrument used to open up that part of the equatorial rain-forest to the benefits of Western medicine and prepare the way for the training and research components of the Yakusu medical service. Impressed especially by the quality and effectiveness of the work carried out by Chesterman on the treatment and control of trypanosomiasis, the government agreed to entrust the Mission Medical
358
SYMPOSIUM-MEDICAL
MISSIONARIES
Service with a whole medical Secteur with a population of over 100,000 people, belonging to seven tribal and linguistic groups. It was this area that witnessed the development of a community health care service that Chesterman had seen in embryo before he left Congo in 1936. The programme was based upon a chain of Rural Health Centres that replaced rather primitive dispensaries. From the outset, they were manned by trained auxiliaries. In all, 18 such health centres were eventually built and staffed; each was in the village of residence of the paramount or local chief, and enjoyed the active participation of village elders and leading inhabitants in its construction and support. At first, the main function of these Health Centres was curative, and the auxiliaries in charge were concerned with the prevailing ills of the people living in the surrounding villages. When confidence and mutual understanding had been established, and the principle of prevention by cure had been accepted in the case of trypanosomiasis, the stage was set for the gradual introduction of preventive measures, health education, baby and toddlers’ clinics, ante-natal clinics, new foods (such as the soya bean and vegetables), fruit trees, selected large eggs (to improve the local strain), etc. (BROWNE,
1973).
The service extended into the local mission schools, which were being organized at that time. The medical auxiliaries gave lessons in hygiene to the scholars in the upper standards, and did stool and haemoglobin estimations on all. As the ancylostome worm-load was reduced by vermifuges and iron mixture was prescribed, the only complaints received were from school teachers perturbed and perplexed by the increasing liveliness and mischievousness of the pupils whose haemoglobin levels were rising. Hand in hand with the practical demonstration of the successof reducing worm-load and the teaching of hygiene in the schools went the activities of the spec%ly trained teams of young men called %aoniteurs d’hvai&ze”, whose tasks included encouraging villagers to-make deep pit latrines-and use them properly and protect them from fliesand dispose hygienically of household waste. Health education was brought to some hundreds of mothers and pregnant women attending the clinics held in the Health Centres. Having seen the dramatic fall in mortality from cerebral malaria from a total of 200 annually to zero, consequent on the weekly prophylactic administration of pyrimethamine to toddlers attending their clinics, the mothers needed no further convincing of the value of Western preventive medicine (BROWNE, 1973). The whole population was vaccinated against smallpox: initial lack of co-operation was overcome when, in the face of a threat of Asiatic smallpox, nobodv with signs of a successful “take” was amona the 14i) victims of the disease. Tuberculosis was brought into the district from time to time, usually froln a big town or by workers on concessionary company plantations, but no secondary case occurred since the index case was diagnosed and notified with the minimum delay. Sleeping sickness continued to occur sporadically,
AND TROPICAL
MEDICINE
since it was quite impracticable to eradicate the vector, but sterilization of the blood of those patients suffering from the disease in its second stage sufficed to interrupt the chain of transmission, and the last casewas cured and discharged in 1947and this in a district where the riparian villages had a prevalence rate of 20 to 25% only 25 years previously. Poliomyelitis posed a threat now and again. Before the advent of a vaccine, when the diseasedid strike, each patient was diagnosed, splinted and isolated, and hygienic precautions were taken within 48 hours of the onset of signs. Tvohoid was brought in from time to time. A cyclsf would arrive-from a distant dispensary bearing a letter; the medical auxiliary sent a specimen of serum for Widal examination, since “the patient had a raised temperature that had not responded to antimalarials, a slow pulse, and a leucopenia; and no parasites had been found in the thick-drop preparation”. A viscerotomy service was instituted following the demonstration of Councilman bodies in a specimen from the liver of a fatal case of febrile jaundice, and the demonstration of yellow fever antibodies by mouse inoculation tests. An annual census of the whole population was carried out, primarily for detecting early cases of trypanosomiasis, but its purpose was broadened to include leprosy, onchocerciasis, yaws, etc., and from time to time other interesting-if not epidemiologically important-conditions, such as tertiary framboesial manifestations (specific depigmentation, juxta-articular nodules and pahnar hyperkeratosis), congenital deformities, filariasis. ainhum. etc. (Bad&x,-1976). As the health centres became part of the accepted pattern in the various agglomerations, satellite treatment centres-two to four per centre, depending on population density and dispersal-were created. The assistants in charge were trained and supervised by the medical auxiliary at the health centre. In turn, the auxiliary and his centre were visited every six weeks by one of the two doctors from the central hospital. Leprosy has traditionally been the concern of Christian missionaries; they showed the way when governments were not interested. Outstanding doctors-such as Ernest Muir, Robert Cochrane, James Ross Innes, John Lowe, and others happily still with us-pioneered in competent medical care, training and research. We were compelled to do something after early prospection journeys had indicated that the prevalence of leprosy was extremely high throughout the district. A comple
0s THE ROYAL
SOCIETY
ROYAL
OF TROPICAL
SOCIETY
MEDICINE
AND HYGIENE,
OF TROPICAL
Ordinary
VOL.
73, No.
4, 1979
MEDICINE
AND HYGIENE
Meeting
Manson House, Thursday,
19th October,
1978
The President: DR. S. G. BROWNE in the Chair
Symposium The contribution
of medical missionaries to tropical
ServiceStLaini;tw-Fh The Leprosy Study Centre, London
Summary Medical missionaries, historically the pioneers in introducing Western medicine into many tropical countries, are today responsible for a significant proportion of health care in several of those countries. Illustrating his theme with references to personal experiences in the former Belgian Congo, the author enlarges on the organization of a church-related comprehensive health care programme based on a chain of rural health centres and satellite dispensaries that brought curative and preventive medicine to the whole population within the area covered. Trypanosomiasis was eradicated, yaws and tuberculosis controlled, cerebral malaria eliminated, worm-loads reduced and nutrition improved. Leprosy was treated within the integrated service as soon as the sulphones became available. Medical auxiliaries and nurse-midwives were trained practically to tackle the local problems. Students from many missions over a wide area went into government, mission and company employ after training. Research concentrated mainly on the solution of pressing local problems, such as onchocerciasis and leprosy, but incidentally investigated interesting clinical phenomena.
Introduction The Centenary of the Medical Missionary Association provides a fitting opportunity not only to pay tribute to a worthy succession of medical missionaries whose training was made possible or facilitated by the Association, but also to glance at the significant contribution made in the past by medical missionaries to the health services in many tropical countries. In the pioneering past, medical missions have noticeably been active; but also today, in some countries, services provided by Christian organizations may account for a quarter of all the health services available, whatever the yardstick employed-doctors and nurses, hospital beds, operations, consultations. With the passing years, as Sir Clement Chesterman has shown in his paper, the emphases may have changed, and the relative importance of medical missions may have diminished as governments have rightly assumed more
medicine
responsibility for the health of their peoples; but their contribution in service, training and research has frequently been of crucial importance in the develooment of the health services. The obvious and acknowledged part they have played has been matched by their catalytic influence on the quality of medical care, supplemented as it has been by the parallel growth of official medical services introduced by the colonial regimes that it is now unfortunately fashionable in some quarters to denigrate. It was my good fortune in 1936 to follow in the footsteps of Doctor (now Sir Clement) Chesterman at Yakusu, and, with my honoured colleagues Raymond Holmes and a team of English nursing sisters attached to the Baptist Missionary Society, to develop a programme of comprehensive health care in an area of some ten thousand square miles in the Oriental Province of the former Belgian Conao. In many ways this service was not typic2 of the average mission hospital of that epoch, but the ideals of community health care embodied and exemplified in the programme have more recently become accepted as the norm for such organizations integrated into government health services. The initiative and flexibility characteristic of many nongovernmental organizations can make a real and lasting contribution to health and serve as an example to official medical services. The Service Component In the 20s and early 3Os, the scene was dominated by the sheer medical needs of the river- and forestdwellers many of whom recalled the horrors of the slave-trade and who were now confronted by an epidemic of trypanosomiasis (CHESTERMAN, 1932) superimposed on holoendemic malaria and endemic yaws. It was the opportunity provided by those medical challenges that assured a genuine welcome for Western curative medicine. “The needle”. which introduced parenterally such effective medication as suramin, quinine and neosalvarsan, was the instrument used to open up that part of the equatorial rain-forest to the benefits of Western medicine and prepare the way for the training and research components of the Yakusu medical service. Impressed especially by the quality and effectiveness of the work carried out by Chesterman on the treatment and control of trypanosomiasis, the government agreed to entrust the Mission Medical
358
SYMPOSIUM-MEDICAL
MISSIONARIES
Service with a whole medical Secteur with a population of over 100,000 people, belonging to seven tribal and linguistic groups. It was this area that witnessed the development of a community health care service that Chesterman had seen in embryo before he left Congo in 1936. The programme was based upon a chain of Rural Health Centres that replaced rather primitive dispensaries. From the outset, they were manned by trained auxiliaries. In all, 18 such health centres were eventually built and staffed; each was in the village of residence of the paramount or local chief, and enjoyed the active participation of village elders and leading inhabitants in its construction and support. At first, the main function of these Health Centres was curative, and the auxiliaries in charge were concerned with the prevailing ills of the people living in the surrounding villages. When confidence and mutual understanding had been established, and the principle of prevention by cure had been accepted in the case of trypanosomiasis, the stage was set for the gradual introduction of preventive measures, health education, baby and toddlers’ clinics, ante-natal clinics, new foods (such as the soya bean and vegetables), fruit trees, selected large eggs (to improve the local strain), etc. (BROWNE,
1973).
The service extended into the local mission schools, which were being organized at that time. The medical auxiliaries gave lessons in hygiene to the scholars in the upper standards, and did stool and haemoglobin estimations on all. As the ancylostome worm-load was reduced by vermifuges and iron mixture was prescribed, the only complaints received were from school teachers perturbed and perplexed by the increasing liveliness and mischievousness of the pupils whose haemoglobin levels were rising. Hand in hand with the practical demonstration of the successof reducing worm-load and the teaching of hygiene in the schools went the activities of the spec%ly trained teams of young men called %aoniteurs d’hvai&ze”, whose tasks included encouraging villagers to-make deep pit latrines-and use them properly and protect them from fliesand dispose hygienically of household waste. Health education was brought to some hundreds of mothers and pregnant women attending the clinics held in the Health Centres. Having seen the dramatic fall in mortality from cerebral malaria from a total of 200 annually to zero, consequent on the weekly prophylactic administration of pyrimethamine to toddlers attending their clinics, the mothers needed no further convincing of the value of Western preventive medicine (BROWNE, 1973). The whole population was vaccinated against smallpox: initial lack of co-operation was overcome when, in the face of a threat of Asiatic smallpox, nobodv with signs of a successful “take” was amona the 14i) victims of the disease. Tuberculosis was brought into the district from time to time, usually froln a big town or by workers on concessionary company plantations, but no secondary case occurred since the index case was diagnosed and notified with the minimum delay. Sleeping sickness continued to occur sporadically,
AND TROPICAL
MEDICINE
since it was quite impracticable to eradicate the vector, but sterilization of the blood of those patients suffering from the disease in its second stage sufficed to interrupt the chain of transmission, and the last casewas cured and discharged in 1947and this in a district where the riparian villages had a prevalence rate of 20 to 25% only 25 years previously. Poliomyelitis posed a threat now and again. Before the advent of a vaccine, when the diseasedid strike, each patient was diagnosed, splinted and isolated, and hygienic precautions were taken within 48 hours of the onset of signs. Tvohoid was brought in from time to time. A cyclsf would arrive-from a distant dispensary bearing a letter; the medical auxiliary sent a specimen of serum for Widal examination, since “the patient had a raised temperature that had not responded to antimalarials, a slow pulse, and a leucopenia; and no parasites had been found in the thick-drop preparation”. A viscerotomy service was instituted following the demonstration of Councilman bodies in a specimen from the liver of a fatal case of febrile jaundice, and the demonstration of yellow fever antibodies by mouse inoculation tests. An annual census of the whole population was carried out, primarily for detecting early cases of trypanosomiasis, but its purpose was broadened to include leprosy, onchocerciasis, yaws, etc., and from time to time other interesting-if not epidemiologically important-conditions, such as tertiary framboesial manifestations (specific depigmentation, juxta-articular nodules and pahnar hyperkeratosis), congenital deformities, filariasis. ainhum. etc. (Bad&x,-1976). As the health centres became part of the accepted pattern in the various agglomerations, satellite treatment centres-two to four per centre, depending on population density and dispersal-were created. The assistants in charge were trained and supervised by the medical auxiliary at the health centre. In turn, the auxiliary and his centre were visited every six weeks by one of the two doctors from the central hospital. Leprosy has traditionally been the concern of Christian missionaries; they showed the way when governments were not interested. Outstanding doctors-such as Ernest Muir, Robert Cochrane, James Ross Innes, John Lowe, and others happily still with us-pioneered in competent medical care, training and research. We were compelled to do something after early prospection journeys had indicated that the prevalence of leprosy was extremely high throughout the district. A comple
