The establishment of an academic health sciences library in a developing country: a case study By Larry S. Ellis, M.S.L.S. Medical Sciences Librarian The University of the West Indies Faculty of Medical Sciences Eric Williams Medical Sciences Complex Champs Fleurs, Trinidad Trinidad and Tobago

The development of a Faculty of Medical Sciences (FMS) and an academic health sciences library for the University of the West Indies (UWI) has proven to be a polemical and political issue due to the depressed economy of the country. Although FMS is still shrouded in politics and controversy after its inaugural year, the Medical Sciences Library (MSL) has expanded its dimensions and is actively developing a biomedical information network within the country. This will result in better dissemination and control of biomedical information. The library now participates in joint projects with other health sciences libraries in the country with the goal of joint automated listings of holdings and shared cataloging projects. This paper examines the development of the library and explains the difficulties experienced in its developmental stages due to politics, the delay in appointment of a medical sciences librarian, and the financial decline in the local economy.

BACKGROUND The Eric Williams Medical Sciences Complex (EWMC), which opened in October 1989, has been plagued with political and economic problems since its inception. Its development was viewed with skepticism by some members of the professional and general public; it has been seen as a drain on the government budget, and it has been termed a "white elephant" [1]. The concept behind the complex's development is attributed to a feasibility study conducted by an international team and funded by the Inter-American Bank. Two of the study group members were from the University of the West Indies (UWI). The study ascertained which faculties of the university system needed to expand for the development of professionals in the region [2]. The study found there was a need for a second facility in the region to train community-oriented physicians specializing in tropical and Caribbean medicine. At the time of the study, Trinidad and Tobago was Bull Med Libr Assoc 79(3) July 1991

Trinidad and Tobago was considered the most affluent island nation in the Caribbean due to extensive oil reserves. The revenue from oil provided funds for a nearly total redevelopment of the country, as well as for innovative projects. considered the most affluent island nation in the Caribbean due to extensive oil reserves. The revenue from oil provided funds for a nearly total redevelopment of the country, as well as for innovative projects. On the recommendation of the feasibility study, and in anticipation of seemingly increasing and unending oil revenues, the government volunteered to provide resources for the development of EWMC, a teaching and research facility that would include the recommended Faculty of Medical Sciences (FMS). Unfortunately, as in other newly rich countries with extensive oil reserves and little financial experience 295

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to deal with such sudden wealth, the decline of oil prices on the world market caused an economic crash that greatly affected the development of EWMC and plummeted the country to developing or third world status. As a result of the economic decline and a change in political regimes, EWMC and FMS development became dormant for three years. The only health sciences library that has been actively involved in providing medical information for health care professionals of Trinidad and Tobago is the Port of Spain General Hospital Library Network. Even this facility does not have adequately trained medical librarians and has not been able to establish cost-effective measures for efficient dissemination of information. Now that MSL of FMS has opened, there is a need for a concentrated effort to form a consortium or network of biomedical information sources within the country and, ultimately, extending to the entire Caribbean region. Most of the biomedical information centers in Trinidad and Tobago have existed for many years. However, during the boom years when the country was financially stable and money was available for new technology, no efforts were made to automate medical library functions due to lack of knowledge and experience. There is a wealth of biomedical information available; however, access to it is minimal. The MSL in conjunction with the Hospital Library Network is attempting to coordinate the collections of journals within the two libraries in one location, and they will share the resources and thus provide improved and cost-effective access to the material.

THE UNIVERSITY

UWI consists of campuses located in three independent Caribbean nations: Jamaica, Barbados, and Trinidad and Tobago. Extramural programs have been conducted on other, smaller islands throughout the English-speaking Caribbean. The university is considered to be one entity and to be supported by all of the governmental bodies within the region; however, in actuality, the individual campuses operate with a high degree of autonomy and receive funding from local governments. The FMS in Trinidad and Tobago is an extension of the Faculty of Medicine located at Mona, Jamaica. The two faculties differ in that the facility in Trinidad and Tobago will consist of and support five schools (medicine, nursing, dentistry, pharmacy, and veterinary science) and will establish the first problembased learning curriculum within the university system once it becomes fully operational. The facility in Jamaica follows a more traditional approach to learning and is not augmented by the other disciplines. 296

ADMINISTRATION AND MANAGEMENT The MSL of the FMS is an integral part of the UWI libraries system. Located in Trinidad and Tobago, MSL reports to the University Libraries of UWI, St. Augustine, and functions as a branch of the main university library, rather than as an autonomous entity within the university libraries system or as a separate department in FMS, such as the departments of surgery or medicine, as recommended by Belleh [3]. Much of the library literature advocates that medical libraries in university schools of medicine should be full libraries in their own right, not branches of the main university library.

The MSL in conjunction with the Hospital Library Network is attempting to coordinate the collections of journals within the two libraries in one location, and they will share the resources and thus provide improved and cost-effective access to the material. During the initial stages of discussion concerning FMS, MSL was viewed as a department within the faculty equal to other departments, with the same aggregate of professorships, readerships, senior lectureships, etc. However, due to the lack of expertise in the development of a medical library and without a director in place to guide policy dev lopment, the university administrators felt that development of MSL would be best administered by Yhe previously established university libraries system, in operation since June 1962. In many organizations within Trinidad and Tobago, unfortunately, no distinction is made between librarians with specialized expertise and training and those who have worked in general school, academic, or public libraries. No established forum or need for a medical librarian had existed, and where there was a need, it was often overlooked. It was generally accepted that a librarian is a librarian, regardless of specialized training. There is a general lack of knowledge and resentment of specialties within the library profession: in this region, librarianship is not highly regarded outside the university environment, and even there, it is viewed with skepticism. The establishment of MSL brings hope that the demonstrated special skills that a fully trained medical librarian brings to a health sciences institution will come to be appreciated. Normally the first person hired during the development of any new medical school library is the director. It is recommended and advisable that the library director report directly to the dean of the medical Bull Med Libr Assoc 79(3) July 1991

A case study

sciences faculty, rather than to the campus librarian or any other administrative official [4]. Many of the applicants for MSL positions had no training for a specialized environment and vast undertaking; however, the university attempted to employ key personnel who would be responsible for development of the facility. Several qualified candidates who were expected to cooperate with the university libraries administration in the library's development were identified and offered the position of director. Unfortunately, due to personal circumstances, slow university hiring procedures, and the gradual nature of the development of the faculty, none of the identified candidates accepted the position. This, of course, would deter the development of any library, but particularly MSL, as the task of developing an academic health sciences library had not previously been undertaken at the Trinidad and Tobago campus.

There is a general lack of knowledge and resentment of specialties within the library profession: in this region, librarianship is not highly regarded outside the university environment, and even there, it is viewed with skepticism. Due to the lack of a director, responsibility for the library's development reverted to the university libraries administration and was delegated to the deputy librarian of the main university library. The library administration, although experienced, seemed more attuned to the needs of a university library and could provide only limited attention to the development of MSL. After the first, unsuccessful effort to fill the director's position, the new government regime halted the development of the complex and FMS in order to reassess its plans in light of the economic recession. The government decided that, because of financial constraints, it was in the country's best interest to examine other alternatives for the use of the complex. Ultimately, the government decided to use the available funds for operation of the complex to provide hospital services and that teaching and research services were no longer viable. Recruiting for FMS positions was stopped, which delayed finding a health sciences library director; without government consent, no work permits could be obtained for faculty members. The academic members of FMS then decided to look at new ways to make the faculty a reality without creating additional financial burdens. They eventually proposed that the faculty would need limited initial funding from the government and that it would Bull Med Libr Assoc 79(3) July 1991

be a quasi-self-supporting entity within the complex. The government accepted this proposal, and efforts were made to fill positions on FMS, including that of the library director. STAFFING AND MANPOWER DEVELOPMENT It is difficult to obtain professional staff for libraries in developing countries; there are urgent needs for college-trained personnel in all departments of government, in professions such as medicine and engineering, and in private business [5]. Recruitment of capable persons for library positions is further hampered because the salaries and prestige of librarians are not sufficiently high to be competitive.

It is difficult to obtain professional staff for libraries in developing countries; there are urgent needs for college-trained personnel in all departments of government, in professions such as medicine and engineering, and in private business. In a male-dominated society such as Trinidad and Tobago's, librarianship is seen as a profession for women. Unlike developed countries where librarianship was founded and developed as a profession by both men and women, in Trinidad and Tobago librarianship has always been dominated by strong women and was not promoted by educational authorities as a viable profession for men. The absence of authoritative male input into the profession caused librarianship to be viewed as a nonprestigious profession and one that would not be selected due to its lack of professional status outside the university environment. A small core of able and devoted persons who have studied abroad provide the existing leadership in the profession [6]. In the English-speaking Caribbean, there is a wealth of library professionals with the capabilities for employment in academic, public, or school libraries; however, a special library such as a major academic health sciences library is a fairly new entity in Trinidad and Tobago, and only recently has the need arisen for qualified trained medical librarians. Brandon stated that "the essential minimal staff in the new medical school library consists of about five professional librarians and a like number of clerical employees, as well as part-time help" [7]. Brandon also suggested a model organizational plan (Figure 1). The initial MSL recruitment effort was difficult; however, three professionals were hired-a catalog297

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Figure 1 Organization model for a health sciences library [7]

er, an acquisitions/ serials librarian, and a reference librarian-as well as a number of paraprofessional, clerical, and attendant staff. The professional manpower needs of the library could not be satisfied from within the region because of the specialization of the library, the subject demands, and professional qualifications. Of the initial staff, only the reference librarian was fully qualified as a health sciences librarian; because of the prolonged period taken by FMS to develop, that person was used, part time, as a liaison for library services to the members of the academic staff who were on the faculty but not yet involved in teaching programs. Only one of the three professional librarians hired under the university libraries specified staffing requirements was assigned to develop MSL. As a result, little was done in the preparation of the books and journals that had been collected over the years in anticipation of development of MSL and even less to train the staff members who had been hired for the development of MSL. The organization of MSL, recommended by the university libraries administration, is shown in Figure 2. Ideally, in the absence of a director, the three professionals should have been working as a team to develop policies and procedures for MSL. The time between the hiring of staff and the opening of the library should have been used for training professional and paraprofessional staff in the work of a health sciences library. As it was, the staff found such work quite different from the work in a general academic library. 298

As an example, it was decided to use the National Library of Medicine (NLM) Classification and MeSH® * to catalog the collection. The cataloger hired had previously used only the Library of Congress (LC) Subject Headings and Classification scheme. Although an experienced professional, the cataloger felt uncomfortable using the NLM systems. It would have been beneficial if, during the time that library development was delayed, the cataloger had worked at NLM or another health sciences library in order to gain practical experience. Similarly, the other staff members hired for MSL received no training related to medical information; because MSL development was inactive and a starting date was not set, the staff members were absorbed into the day-to-day work force of the main university library and had very little, if anything, to do in connection to planning the facility for which they were hired.

In most developing countries where universities are supported by local governments, financing may be adequate on paper; however, the hard currency to support these budgets is not available because of foreign exchange difficulties and currency devaluation. FINANCIAL STRUCTURE The primary problems in any country relate to finances, but they are particularly acute in developing countries [8]. In most cases, immediate financial returns have guided priority setting; since there usually are no financial returns from library services, libraries do not receive high priority [9]. Unlike many new health sciences libraries in developing countries, it is interesting to note that MSL of UWI, Trinidad and Tobago, was adequately provided for in both operating and capital funds. An Export/Import Bank loan to the government for the development of EWMC provided most of the capital funding. The library was spared the usual unsuitable accommodations of many developing countries as described by Falayi [10]. In most developing countries where universities are supported by local governments, financing may be adequate on paper; however, the hard currency to support these budgets is not available because of foreign exchange difficulties and currency devaluation. Because of low priority and low awareness of library

*MeSH is a registered trademark of the National Library of Medicine.

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A case study

Figure 2 Organization chart, Medical Sciences Library, University of the West Indies CAPUS

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2 LIBRARY ATTENDANTS

value, a meager segment of national resources is devoted to libraries [11]. MSL was planned as a department in FMS similar to the departments of anatomy or physiology and with the same staff ranking. In 1988, the Trinidad and Tobago currency was devalued; this supported the university libraries administration's justification for amalgamating all libraries on the St. Augustine campus. The devaluation and subsequent reduction in the staff of the main university library supported the position that this was a cost-effective way to manage a growing library system. The process was premature, however, and has proven to need further study, parBull Med Libr Assoc 79(3) July 1991

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ticularly with the retirement of both the campus and deputy librarians shortly after the opening of the new main library. No permanent university library administration was in place before mid-1990. In merging the St. Augustine campus libraries, the main university library, instead of reducing its services to the new staff level, conscripted staff members who were on the MSL budget under the pretext that they were performing duties for MSL at the main university library. This actually kept service levels status quo at the main university library and reduced MSL to the status of a branch library, even though, upon reaching its full potential, services and user com299

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munity would be equal to and perhaps surpass those of the main university library. There were many difficulties in starting MSL and as there was no director in place and given the financial constraints, the possibility that the merger of libraries would restrict the new library's growth was not considered [12]. Unlike the university libraries budget, that of MSL came directly from FMS, thereby making it financially independent and providing a degree of autonomy from the consolidated system. In budget procedures, MSL was treated as a department of FMS even though there had been a merger of campus libraries and there are few disadvantages to this arrangement. The budget for FMS and MSL was changed to a triennial basis and especially supported by the government. Many of the financial problems due to development will be discovered during and after the end of the current triennium, when the faculty determine whether or not the fiscal arrangement has proven viable in spite of the quasi-self-supporting status of FMS. At that time, provided the budget is still connected to FMS, MSL will be expected to justify its existence and compete for new funds with the other departments, unless by then MSL has been linked budgetarily to the university libraries. Having its own budget allows MSL to put in place needed services and to control its development. If the library is required to request funds from the university libraries budget, growth and development will be slowed as, in a developing country, management styles are not often participatory or delegative. Further, the current method of budgeting also affords MSL, within the university libraries system, an autonomy that limits fiscal control from the university libraries management hierarchy.

CONCLUSION FMS and MSL, although still in its rudimentary stages and having completed its first academic year, remains the subject of controversy. There are questions concerning viability, accreditation, usefulness to the country and the Caribbean region [13], and even whether or not FMS will be open for an additional year [14]. There is, however, much support in favor of the faculty, including articles that explain in detail how the faculty came into being, the reasons for its existence, and the benefits of its location in Trinidad and Tobago [15]. Some express the view that local medical students need to study at home where they can have the support of people who care about their welfare, rather than having to struggle with their studies abroad. The pros and cons and the political and polemical debate that surround EWMC and, thus, 300

FMS, promise to continue until it has proven itself academically successful, financially viable, and an established facility in the country. Regardless of the politics, there is a great need for MSL. Trinidad and Tobago has many health care professionals who, when trying to keep abreast of current trends in their respective areas, have been forced to obtain current literature by unconventional methods. Often, they cannot gather the necessary information because of the cost and time involved in obtaining it.

Trinidad and Tobago has many health care professionals who have been forced to obtain current literature by unconventional methods. Often, they cannot gather the necessary information because of the cost and time involved in obtaining it. The Pan American Health Organization (PAHO) has planned a regional network of biomedical libraries and documentation centers throughout Latin America and the Caribbean and has established a regional library in Brazil at the Latin American and Caribbean Health Sciences Information Center (BIREME). This program, however, has been concerned with the promotion and strengthening of health care information in the Spanish-speaking countries in the region [16]. It may now be time for the English-speaking countries to establish a network; Trinidad and Tobago could develop as an example by establishing a practical network. The country is small and resources are limited, but the automation capabilities of FMS MSL could demonstrate innovative systems to disseminate and control biomedical information resources. Many more projects are being planned, such as shared cataloging, advanced training, interlibrary lending, electronic mail, and a general effort to define and develop a local medical information network. The deterioration of the economy dictates that libraries pool their resources to meet a growing demand for biomedical information in the region. The future is here, and the libraries have begun to develop their role in the dissemination of biomedical information in the country and the region. Development must now be defined and needed services provided. REFERENCES 1. SINGH H. Mount Hope's white elephant: another view [editorial]. Daily Express; nation newspaper Trinidad Tobago 1987 Jul 2:9. 2. MORRIS P. Trinidad wants more autonomy for University of the West Indies' campuses. Nature 1978 May;273(4):4. Bull Med Libr Assoc 79(3) July 1991

A case study 3. BELLEH GS. Medical librarianship in Nigeria-a review of the literature and comments on some problems and prospects. Bull Med Libr Assoc 1975 Apr;63(2):199-207. 4. BRANDON AN. The development and organization of a new medical school library. Bull Med Libr Assoc 1964 Jan;

52(1):188-95. 5. REYNOLDS CF. Medical libraries in developing countries. In: Davis KE, Sweeney WD, eds. Proceedings of the Third International Congress of Medical Librarianship, Amsterdam, 5-9 May 1969. Amsterdam: Excerpta Medica, 1970: 462-6. 6. IBID., 463. 7. BRANDON, Op. cit., 190. 8. REYNOLDS, Op. cit. 9. FALAYI SO. Problems of medical information systems and centres in developing countries. Survey of work in Africa. In: Davis KE, Sweeney WD, eds. Proceedings of the Third International Congress of Medical Librarianship, Amsterdam, 5-9 May 1969. Amsterdam: Excerpta Medica, 1970: 452-61.

10. IBID., 454. 11. MCCARTHY C. Medical libraries in developing countries: an international approach. Int Libr Rev 1978;10:435-46. 12. BELLEH, Op. cit., 203. 13. LoPEz S. Student fees a burden; medical school facing closure. Daily Express; nation newspaper Trinidad Tobago 1990 Jun 14:1. 14. LopEz S. That Mt. Hope medical school; can T&T afford it? Sunday Express; nation newspaper Trinidad Tobago 1990 Jun 17:5. 15. RENwICK D. Nothing complex about Mt. Hope. Sunday Express; nation newspaper Trinidad Tobago 1990 Jun 24; Section 2:2. 16. BONHAM MD. BIREME: Latin American and Caribbean health sciences information center. Bull Med Libr Assoc 1990 Apr;78(2):119-23.

Received August 1990; accepted October 1990

FROM THE BULLETIN - 25 YEARS AGO

Extramural programs of the NLM By Marjorie P. Wilson, M.D., Carl D. Douglas, Ph.D., David F. Kefauver, National Library of Medicine, Bethesda, Maryland The uses for which grants made by NLM under Section 397 of the Medical Library Assistance Act may be used include, but are not limited to, the acquisition of books, journals, photographs, motion pictures and other films, and other instructional materials; cataloging, binding, and other services and procedures for processing library resource materials; and the introduction of new technologies and methodologies in medical librarianship. The amount of the grants will be related to the annual operating expenses of the library and will decrease regularly in amount annually for a five-year period. The purpose of this approach is (1) to make a significant but relatively short-term grant to bring basic resources to a more useful level, and (2) to encourage increased support to the library by the parent institution on a continuing basis to compensate for the decreasing federal contribution. The magnitude of the need of library resources cannot be accurately measured. The present level of collections, budgets, and personnel in various types of libraries has been examined and compared to suggested standards repeatedly. Numbers of volumes unrelated to the scope and quality of the collection are essentially meaningless. The numbers of professional medical librarians or their equivalents can only be estimated in the most gross manner. Expenditures for books, periodicals, and binding per medical student last year, for example, ranged from $26 to $613.20. What can be said is that resources generally fall short of the requirements for good library service. Bull Med Libr Assoc 1966 Oct;54(4):295

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