FEATURE ARTICLE  FOR THE LIVERPOOL SCHOOL OF TROPICAL MEDICINE

 

INTO AFRICA

 

When Dr. Pat Nickson of the Liverpool School of Tropical Medicine had the vision of establishing a community based health care centre in Zaire, she knew realising it would not be easy.  Yet even she did not anticipate having to cope with war, drought, famine and cholera along the way! 

 

 

 

There is no electricity and no water.  No roads, no sanitation system and no telephones.  The nearest postal address is two countries away.  Drought and flooding are endemic.  Hyper-inflation and devaluation are ever present.  Abject poverty is ubiquitous.  And until recently a bloody civil war was raging.

 

Not exactly the most promising of environments for creating a modern health care  training establishment.  Yet against all the odds,  that is exactly what is happening at the the Institut Panafricain de Sante Communautaire or IPASC at Nyankunde in the Democratic Republic of Congo (former Zaire).

 

The institute largely owes its existence to the vision and persistence of one woman. Dr. Pat Nickson of the world famous Liverpool School of Tropical Medicine was growing increasingly  concerned  that of the few institutions specialising in tropical medicine, even fewer were actually located in the tropics.  When it came to French speaking Africa, they were non-existent. 

 

The only alternative for doctors and nurses wanting to extend their training was to leave home and take a course in Europe.  Taking her cue from Mahomet,  rather than bring the students to Liverpool,  Dr. Nickson decided to take Liverpool to the students.

 

Essentially, Dr. Nickson’s vision was to create a training and research centre that would serve the needs of  rural African communities far more effectively than the existing system.  This had changed little since colonial times and, slavishly  following the western model, was based on teaching hospitals to which most of the population had little access. 

 

Accordingly, although most health care was practised at  local health centre level, the nurses who staffed these centres were not receiving the training which enabled them to help their people.  Poor basic health amongst their communities was the result, with malnutrition rates of 53% not unknown.

 

Central to Dr. Nickson’s  philosophy was the desire to not  impose programmes in the traditional European manner but to empower communities to tackle their own health problems. Graduates should be trained to go back into their own villages and not just treat sickness but help tackle root causes of bad health and poverty, such as poor  agricultural practice.  Indeed,  it was to be considered as important to teach people how to look after their cattle as to dress their wounds.  It was also desirable to accommodate some aspects of traditional  herbal medicine and respect the local culture - although without going so far as to embrace the witch doctor!

 

So much for the theory.  How about the practice?  Apart from all the normal obstacles to getting a venture off the ground, in this case there were some very unusual extra hurdles to be negotiated.

 

First, of course,  there was the total lack of infrastructure, and the kind of practical support normally taken for granted.  As if total lack of sanitation and power were not bad enough, imagine organising a construction project when there are no roads? Or communicating with sponsors when there are no telephones or  postal system?  When  most academics talk in terms of  building a school, they mean building a reputation.  To Pat Nickson and her colleagues building a school meant just that  -  building a school.  With their own hands, right down to making the bricks.

 

 

Nevertheless, all such obstacles were somehow overcome and the IPASC was established in June 1992 in the town of Nyunkunde in North East Zaire. The first students were admitted, with over 100 graduating from the Institute community health course by 1995. The initial steps were taken to realising the vision of better community health care in rural Francophone Africa.

 

Then, in December 1996, a full scale civil war started.

 

Nyunkunde soon found itself uncomfortably close to the war zone, with fleeing refugees and retreating soldiers an all-too common sight on the roads in and out of the town. The situation became extremely tense, with rumours abounding among students and staff alike. Rather than teach medicine, it was often all Dr Nickson and her staff could do to reassure students that they were not about to be shot. A task made rather more difficult when a rocket landed in a staff member's garden!

 

Fighting, looting and pillaging were constant problems around IPASC. When soldiers were sent to protect the town, their presence usually brought more trouble than it deterred. On one occasion the school motorbike upon which staff relied to get around was stolen. It was later found at the airstrip, about to board the next plane out! Another time, staff got wind of an imminent 'visit' and hid all the school's PC's in the bush - only to forget where they were and have to later undergo a frantic 'treasure hunt' when the danger was over!

 

More seriously, female students had to flee into the bush to avoid rape when their dormitory was broken into. Pat Nickson and a full class of students even spent an afternoon held at gunpoint by a rebel soldier.

 

As might be expected, communication with the outside world at this time grew even more difficult. Ironically, in a situation where such basic necessities as the post were missing, advanced electronic communication in the form of E-Mail via the IPASC's battery powered radio became a lifeline to the outside world. Transcripts of E-Mails sent at this time to the School of Tropical Medicine in Liverpool make both fascinating albeit harrowing reading.

 

Many betray a typically phlegmatic frame of mind:

 

'I do not know how often I can contact you - I still have my place reserved on the last plane out!'

 

'It's late, so I must close. we all hate the nights. With no power, it is so dark. Even my solar lamp has just died on me. Each morning when I wake up I pinch myself at the joy of seeing light - and having survived another night!

 

However, others reveal the full seriousness of the situation:

 

'Please ensure all communications are treated very sensitively. One mistake can be fatal to us.'

 

'I am listening to the news again, and wish things could move faster. Thousands and thousands are dying while we talk and plan.'

 

Inevitably, the pressure on Dr. Nickson to evacuate became overwhelming, not least from her own staff who were in fear of their lives. Although IPASC never ceased to function, for five weeks at the height of the fighting there was very little activity apart from survival and staff and foreign students left for Uganda.

 

By February 1997, however, the situation gradually began to improve. With the help of the indomitable Cessna pilots of MAF - Missionary Aviation Fellowship - people were able to return to Nyankunde and a normal curriculum became established. Most encouragingly, from May the institute began to enjoy the active support of the new, elected government of the Democratic Republic of the Congo. No longer faced with life or death situations on a daily basis, Dr Nickson and her colleagues could begin to concentrate on relatively prosaic matters such as obtaining funding for a new degree course.

 

Today, buildings have been repaired, bullet holes filled, fences mended, livestock replaced. Other scars are proving more difficult to heal. When she sees the melancholy and confused expressions on the faces of hitherto happy, well adjusted people, Dr. Nickson wonders just what it is that they have seen.

 

For many, the first thing that must be recovered is the will to live itself. What is more, as so often seems to happen, the war was followed by drought and famine in Central Africa, plus localised epidemics of cholera.

 

In the face of such adversity, what successes have so far been recorded? IPASC is now applying to the WHO for funding for the third phase of its development. Certificate and diploma courses are well established at Nyankunde, with 12 full-time staff and 80 students now attending. Most notably, a new category of community health worker has effectively created by the institute radical curriculum. At alternative ends of the academic scale, the long awaited degree course for nurses and para-medics is due to commence in September 1998, while a new emphasis has been placed on admitting school leavers.

 

Outside the formal tuition delivered in the classroom, the School's 'Good Motherhood' programme, goes from strength to strength and now supports 19 districts. True to the doctrine of taking health care out to the community, this programme aims to give rural midwives the support they need in the villages.

 

New building is proceeding apace, conference, library and staff housing all in advanced stages of planning. Even more important, the capacity of staff to be able to respond in times of disaster has been noted, with senior staff such as Dr. Nickson herself and Dr. Francois Mewema in great demand for consultancy work with agencies such as the UN and Oxfam and as delegates in conferences across Africa. The value of IPASC's unique links with the WHO and the Liverpool School of Tropical Medicine have also been proved.

 

Perhaps the most encouraging signs of all, however, are to be found in the faces of the suffering children whose quality of life is being slowly improved. Sights such as these give Dr. Nickson and her staff all the motivation they need.