PEDIATRIC EDUCATION IN INDIA AND CEYLON*

C. C. D'SILVA

Colombo

Fducation in pediatrics as in every other subject must be corre- lated to the general needs of a country as well as the state of child- health in relation to the general health whether the former is improving at the same rate or faster or slower than the latter. In Ceylon, for instance, 1 have shown in a recent paper read before the University, that though there has been a phenomenal reduction in both infantile and general death rates in the last three years due largely to the control of malaria, yet the age wr iod 1--5 years has lagged behind the former two groups in the improvement of the mortality rates and therefore I have called this age period a relatively neglected group. Further, the vital statistics tables have shown that the incidence of infantile diarrhoea under 2 years in relation to diarrhoea in the population over 2 years is very much worse in i949 than in 1945. I quote from the Registrar General. " I t is significant that the number of deaths of persons aged 2 years and over has been decreasing year after year, while in the case of children under 2 years the position is reversed, so much so tha~ while in 1945 the number of deaths among the latter was about one-fourth of the former, it now amounts to about two thirds." Again from mortality rates of tuberculous meningitis I have shown that there has been an increase of 115% per I million of total population and x4o% per I million of o - -5 years population in the period I945---49 over the' period i936---4 o.

in addition, by routine blood counts in the wards we have shown lhat the average red blood cell count of 46I Ceyh)nese children under io years is 2.6 millions per c.mm. and the average haemoglobin content is 8.2 gms. pet Ioo c.c. (Sahli), (the normal over-all standards for these age groups being 4.1-, million and 11. 7 gms. respectively). 66% of the children as regards red blood count and 47% of the children as regards haemoglobin content are below 75% of the above standards; 62% of all infants and children in our wards from birth to ten years of age showed the presence of intestinal parasites, ow;r 69% of this total being due to Ascaris either alone or in combination with Ankylostoma. Trichuris or Giardia. These facts show that the four major conditions we haw~ to study and therefore educate our doctors about, are malnutrition, worms, diarrhoea and tuberculosis. I do not think the position of India is very. different except in so far as malaria is concerned which is now no problem with us at all.

From the l"aculty of Medicine, l'nivelsity, (;olomt,o.

Pediatric Education in I~dia d~ CeyIo~,--D'Silva 77

Therefore, the position with regard to both preventive or social as well as curative pediatrics is quite different from that in more advanced countries and the specific lines .n which education should be given and the speciiic conditions which need emphasis are also different. Having said so much about the differences let us see where there should be no differences, whatever the geography, history, culture and civilisation of a country are. I quote from tile Cohen report, "A sound and adequate training in pediatrics is essential to the practi- tioner, whatcw.'r branch of medicine he intends to practise. The seeds of adult disease are frequently sown in childhood and many diseases manifested in the child continue into adult life such as rheumatic heart disease. The practitioner must be able to trace the natural history of such disease and to do this he must be properly trained in pediatrics." And again, "Pediatrics has a valuable contribution to make to the training of a good doctor. First, perhaps more than in any other part of the course, it helps to stress the preventive aspect of medicine, for pediatrics includes in its scope the physical, mental and spiritual care of the child both in health and in desease, a charge fraught with great possibilities for good or for evil in childhood and adult life. Sludents will find in child life numerous illustrations of the significance and importance of prophylaxis, the influence of environment on health and the reaction of the individual to his environment. Secondly, in dealing with children, the student learns with special force the value of histmy taking and the need for careful clinical examinations. Thirdly, no other part of the course serves so well to stimulate the development of those personal qualities which are essential in a good doctor, such as patience, gentleness and kindness to the patient."

Pediatrics should deal not only with the individual ?child or adoles- cent in health and sickness but also with his environment whether at home, a! school or at work. As the Goodenough report says there are two good reasons why medical practitioners should be well w.'rsed ii~ the care of children in sickness and in health. First, a considerable part of the practice of the average family doctor is concerned with children. Second, the protection of child life is vital to the future of the nation and lhe raising of the standard of child health provides one of the most promising means of securing a general improvement in the health of the community. It is therefore of the greatest importance that medical students should be properly trained in this branch of medicine and that, throughout such training the emphasis on the nutrition and development of normal, healthy children should be as great as on the treatment of sick children.

Pediatrics more than any other branch of medicine should stress and emphasise lh~,. importance of prevention and therefore there must be closer collaboration with the departments of Public Health or Social Medicine. In my own University the professors of public health and pediatrics exchange lectures. The former lectures 1o final year students who have already finished their clerking in ix2diatrics on

78 Indian Journal of Pediatrics

normal growth and development and the influence of environment on disease, while I lecture to the third year students who are doing, at that moment, intensive courses in public health and pathology as well as their clinical appointments but have not yet commenced their pediatric clerking, on what is a normal child, how can one detect early signs and symptoms of deseases, how do organs and systems and diseases in children differ from the corresponding ones in adults, what is the importance of knowing normal rates of growth and development in the detection of early diseased conditions, how does environment affect children, etc. ? Though there is bound to be overlapping between the two lecturers yet the fact that he, the professor of public health, correlates environment with health from his angle and I, the professor of pediatrics correlate disease with environment from my angle, does, we believe, give the students a fresh view not only of disease but also of health. This is a practice that should be universally applicable though the specific points to be stressed may be different in different countries.

The Interim Report of the pediatric committee of the Royal College of Physicians (England) in 1945 recommended that pediatrics should be regarded as a major clinical subject and emphasis must be laid on the adjective major because while certain universities and schools have at last seen the light and established chairs or departments of child health or pediatrics, yet they are still chary or averse to giving to pediatrics that amount of time and importance in the students' curriculum as is given to medicine, surgery or obstetrics or even a fair and just ratio of such time. Again, we must stress that this is because pediatrics is still looked upon as a speciality or a small subdivision of general medicine and not a major fundamental subject of the same importance as any one of the above three. As far as the future general practitioner is concerned, surely, any un- biassed mind will at once admit that pediatrics is more important than surgery. The hours spent by a medical student looking on or handling forceps and other paraphernalia of surgeons doing major operations and that for a period as long as six months in most medical schools, are hours that are all wasted. If a man is going to be a surgeon, he will be adequately trained for it after graduation. I quote from the 13. M. J. of 26. 8. 50 on 'Some Comments on Medical Education in Great Britain' by a London medical student, "Considering the relative positions of medicine and surgery in general practice today, it is remark- able that the surgical dressership should still occupy as many months as the medical clerkship and equally strange that many surgeons should insist on their dressers being present at operations. Major surgery is essentially a post-graduate subject and if six months are to be spent on surgical dresserships very much more of this time should be spent on minor surgery".

The Planning Committee of the Royal College of Physicians, London, says this, "That pediatrics should be regarded as a major

Pediatric Education in India & Ceylon--D'Silva 79

clinical subject is justified from the practical standpoint because the care of infants and children is a not inconsiderable part of the work of the general practitioner and is of the utmost importance for the future of the people. It is also justified educationally. Child health arouses the students' interest to a greater degree than any other study, except obstetrics, in measures for the maintanance of good health a,; opposed to the recognition of the signs of disease. Diseases process- es are seen in their early- stages and the influence of environmental factors in the genesis of disease is clearly displayed. No other branch of clinical work puts a greater premium on powers of observation and none so easily elicits the student's sympathy with his patient."

But there must be a great measure of freedom so that each university and facul.ty may emphasise those aspects of medical education which it thinks most important and there must be no insist- ence on our part as pediatricians on what we consider our just dues. Insistence will only breed resistance. Time alone will show the resisters what is right and not who is right. Let us see what is the aim of under-graduate medical education. As the Goodenough Report says and I cannot express it half as well, "The aim of under-graduate medical education is to guide students to the development of those qualities of mind and character that will enable them when qualified to give maximum service to the community;" and again, " A general practitioner should possess a scientific foundation for his professional work and a proper outlook on the social aspects of medicine and the promotion of bodily and mental health. Able to observe accurately, reason logically and assess the claims of new knowledge, he should also possess a svmpathetic understanding of people and their environment. Under-graduate medical training must be organised and conducted so as to constitute a real discipline which xxill mould and develop the student's personality and character, reinforce his natural ability, stimulate to the highest degree his interest in his future profes- sional work and inculcate sound judgment and habits of industry, observation and application."

Whatever happens the essential unity of medicine must be pre- served and tile teaching in the various stages and subjects so organi.~ed that the whole becomes a smooth and logical development. Emphasis must be placed on "the inculcation of fundamental principles and methods rather than on the implanting of a mass of factual knowledge." (Goodenough Report)

The overcrowding of tilt, curriculum must be avoided and no new subjects or hours should be addvd unless some old ones are pruned and substituted for. The student's life is not a happy one, what with lectures, lecture-demonstrations, ward-classes, ward rounds, O. P. D.'s, tutorials, post-mortems, etc. etc., he is indeed a veritable camel groan- ing under his burden and looking with eager eves towards the green casis, and we should not thoughtlessly and wantonly add to the burden which is already near breaking the poor camel's back. " I t is altogether

8o I~dian Journal oJ Pediatrics

too burdensome to the student and to his teachers, it is also quite un- necessary, to attempt to cover the whole field of present-day knowledge of disease and its management; to attempt it defeats the purpose of sound education by overcrowding time and mind, robbing the student of all chance of contemplation and by default, rendering the basis of his beliefs unsound." A ruthless pruning of the curriculum is urgently necessary. (Goodenough, Pp. 44).

"The student should receive preparatory instruction in his courses ot biology, physiology, anatomy, pathology, public health and psychology which will turn his attention to the growth and development of children and to the disease and morbid processes which are peculiar to childhood." (Interim Report of Planning Committee of the Royal College of Physicians, Pp. I.)

It is desirable but often impossible, that pediatric clerking should follow obstetrics. In my own faculty this is not done, but undoubtedly it should be. The period of clerking should, in my opinion, be for a minimum of three months during one month of which the student should be in residence. I deliver three or four preliminiary lectures which are the ones I exchange with the Professor of Public Health. In one of these I teach the students how to take a pediatric history and examine a child stressing the importance of a full diatetic history, the motor mental development, the social environment, growth of child and in the general examination stressing points that show us whether the child is well or badly nourished. In their final year, i. e. after they have done their pediatric clerking, they are given a course of approximately 26 lectures once a week throughout the whole year. Six of these are delivered by a child psychiatrist on behaviour problems and four by ,,he Professor of Public Health, as mentioned earlier, on growth and development. These lectures should, I believe, be delivered during the same time that the student is doing his pediatric clerking but roving to the overcrowded curriculum and pediatrics having just been recognised as of sufficient importance to merit a chair, it is impossible to fit the lectures in exactly where they should go. Further, the students have eight ward rounds in a maternity unit on the care of the new-born and a few attendances at a Child Welfare Clinic run by the Professor of Public Health. In addition, we have just commenced a post-natal clinic for following up babies born at the University Maternity Unit which student will be expected to attend while doing their obstetrics posting once a week for eight consect'.tive weeks. All this totals to about 2re hours spent on pediatrics, preventive and curative. The student spends 588 hours on general medicine, lectures, lecture demonstrations, ward rounds and out-patient clinics. So, I think pediatrics gets a fair and full share of the student's time and it is difficult to get any more on the present set-up. If I were asked how this could be improved I would say that pediatric clerking should be done after obstetrics and gynaeco- logy and not before. It has also not been found impossible to make

Pediatric Education in India ~~ Ceylon~D'Silva 81

residence in the hospital premises compulsory owing to lack of accommodation.

INFECTIOUS DISEASES.

In the plans for the expansion of the children's hospital in Colombo there is provision for a separate, segregated ward for infectious diseases. I think it is most important that the pediatrician should teach or have some part in the teching of infectious diseases, the vast majority of which have their greatest incidence during the years of childhood. It is therefore necessary to have close co-operation between the staff of the Infectious Di~ases Hospital and the pediatricians. The difficulty at the moment in Ceylon is one of geography as the in- fectious diseases hospital is miles out of town and transport is not too easy for the student who usually winds his way hither and thither on a push-bicycle.

~OCIAL ENVIRONMENT.

In the present circumstances, I believe, it is most important for students to learn at first-hand how their patients live at home, how bad housing, overcrowding, poor water-supply, unprotected wells, unboiled water, promiscuous def~ecation, lack of general cleanliness in the home, poor !)ersonal hygiene and the contamination of food by flies, all contribute to the tremendously high incidence of common infectious conditions, such as, bowel and respiratory diseases and the direct relationship between dirt and flies and promiscuous defaecation on the one hand and intestinal parasites on the other.

It the students visit the homes of the children and see the condi- tions for themselves, they will not onIy be able to give friendly and valuable advice on how to better these surroundings, but also their views on the relative importance of disease and health will be re-orientated and they will, I hope, begin to realise that what we need as priority No. i in our countries is not m o r e hospitals; m o r e clinics and m o r e

drugs but better housing, higher wages, higher standards of sanitation and hygiene in the home and a raising of the level of general education and literacy, especially among xxomen. In Ceylon, only I in 3 women can read and write. This, I believe, is higher than that in your country but it is still far short of what we desire. Maternal intelligence and knowledge are two of the most important, factors in the prevention of disease and attainment of health.

'~VELL- l'~ ABY CLINICS.

I think attendance of sludents at these clinics is most important. If possible, one should be attached to the maternity unit where the students do 1heir obstetric training and the pediatrician should run this clinic and advise the mothers regarding baby care in the presence of the students. The latter will also see the further progress of the infants born in the hospital and will be impressed with the importance of the follow-up of normal, healthy infants. This is the place where advice should be given repeatedly to mothers on the importance of

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82 Indian Journal o[ Pediatrics

early supplementation of milk with cereals, fruit juices, cod-liver oil and later protein food. The trouble in Ceylon, as I am sure it is in India too, is to get mothers to practise what we preach ; they agree silently and good-humouredly with all we say and then go home and do the opposite. That is why home visiting by students, nurses, school teachers and social workers is so important in building a healthier race. They will be able to check up on whether advice given is actually followed or whether the bad neighbour is upsetting the good doctor's work.

There is no question but that there is a great deal of "slack" in the existing curriculum. I think in the present circnmstances nothing should be added unless something is subtracted and the total burden on the student should under no circumstances be increased. I do not think we pay sufficient attention or respect to the views and opinions of the students themselves. On the other hand students' opinions and views should be more organised and rationalised and less individual and vociferous. I believe that there should be an organisation like an All- India and Ceylon Medical Students' Association which by sheer weight of numbers and authority should be able to make its influence felt in the councils and senates and faculties of our respective Universities and medical schools.

The time for stressing the necessity of establishing chairs of Pediatrics, (or a term I prefer) of child health is long past. Those who dally, discuss, dispute and delay to act will pay for it sooner or later in the lower standard of efficiency of the doctors they turn out in comparison to those progressive schools which have already established these chairs. Further, though there should be full c0- operation and integration with other departments, I do not believe that pediatrics can ever claim its rightful place as a major clinical subject unless its department is compIetely independent of every other depart- ment. At present where this is not done, it is looked on as the Cinderella of clinical medicine, and any recognition given to it is not only disputed but also belated. However, time marches on and before the end of another decade I predict that eve D' University of good repute in this great country will have a chair or at any rate a department of child health, else it will not be worthy of the name of a University--Cinderella will meet her Prince and will live happily ever after.