Submitted by G M Kellerman, Hunter Area Pathology Service, Newcastle, Australia
Much has been written and spoken about technology transfer during the last several years, but I believe that the transfer of analytical and reasoning skills in the collection and utilisation of information is as important in its own way as the transfer of technological skills. Over the last 2 decades I have been involved in two successful examples of skills transfer.
From the two examples described, the model identified requires the intellectual contributions of two types of person. First, there must be a farsighted individual(s) in the recipient country, with the requisite authority and the ability to analyse the current position in that country and the "advanced" world, to identify what is both necessary and feasible over a time span of a decade or so. Second, there must be an individual(s) in the donor country(ies) willing to provide the intellectual input over a long time interval, with command of the necessary resources so that there is no financial drain on the recipient group. Lastly, there must be mutual respect and trust between these two sets of individuals and their colleagues on both sides of the program. The amount of financial resources is not set - one of my examples cost of the order of $US 100 million over 20 years, the other has cost to date about $US 30,000 over about 10 years. In the following discussion, I have not identified by name any individual or organization, to avoid potential offence to anyone else. In any event, there are always several people involved - even Nobel Prize winners have an extensive support group who do much of the actual day-to-day work.
The first example is that of the International Clinical Epidemiology Network (INCLEN), a worldwide program of medical research training for the developing world, set up with the support of the Rockefeller Foundation over the two decades from 1980 - 2000. The initial impetus came from Dr Kerr White, whose book entitled "Bridging the Gap" gives a detailed history of his insights into the developing gap between public health and medical practice dealing with illness. This book details his negotiations with many people to initiate a program to train young medical faculty members in the then developing world in the skills necessary to perform research into the real health problems of their communities, and their management. This training was to be based on a rigorous epidemiological and biostatistical foundation, with research projects using these skills, ultimately in some 30 countries throughout the world. It was set up initially in 3, later more, "training centres" in North America and Australia, where the candidates each spent a year in fundamental study and coursework, accompanied by project planning. This theoretical training was followed by performance of the research in their own community with some limited financial support, leading to the award of a Masters degree after successful completion of the entire program. Senior professors from the recipient countries were critical in setting the original goals and strategies to achieve the end result.
Over about 10 years commencing in 1983, with the acceptance each year of some 6 candidates in each training centre, some 200-300 successful graduations were achieved. These graduates set up clinical epidemiology units in their own countries where they continued to work and to extend the training to other members of their medical services. There were smaller, but important extra developments such as short courses for special skills, and longer courses for PhD training for especially interested and capable candidates, along with acceptance in the training centres of variable numbers of non-INCLEN candidates who had support from other financial sources such as WHO.
The next step was the transfer of the training role from the "developed" world centres to some of the clinical epidemiology units. Collaboration among the three units in Thailand enabled the development of a Thaiclen consortium for training in that country and this can be traced back to initiatives in 1987. A number of collaborative efforts in setting up single or several country training centres on this model have occurred over the years - anglophone Africa, China, India, Latin America, and South East Asia, the last including Philippines and Indonesia. Some of the non-INCLEN trainees who participated in this program have set up training centres of their own. The Fondation Merieux committed resources, along with faculties in France, to the development of a similar collaborative training program for francophone Africa which has still to reach its final stages.
Two phases in the development of this program can thus be identified. The first was the initial skills transfer, from developed to developing world, of research methodology based on epidemiological and public health principles. The second was the subsequent rapid development of training capability by the former "pupils" so that they could continue the process with their own intellectual resources. In all, there have been hundreds if not thousands of people involved in training and receipt of training, the outcome of which has been a quantum shift in operations in medical faculties in dozens of countries. The success of the whole can be traced back clearly to the inspiration of a few farsighted individuals and the willingness of the Board of a large Foundation to commit great resources over a long period.
The second example is a purely personal one, which commenced when I was requested, at a meeting of the Asian Pacific Congress of Chemical Pathology, by a Professor of Biochemistry from Ho Chi Minh City to attend his conference the following year. I attended and gave a short paper on our problem based medical course, stressing the integration of basic science and clinical aspects. Afterwards, I stayed on and gave several talks on the potential contribution of clinical chemistry tests and their interpretation to the clinical judgment about a patient problem, to an audience of about 25 people. A feature of these sessions was the presence of a superb interpreter, a physician trained in endocrinology who had a total command of English. In response to the success of this visit, I have made similar visits each year thereafter, following an agenda prearranged by the local people with clinical presentations of interesting and challenging patient problems. I discussed the value and interpretation of the tests actually performed, with emphasis on the biochemical, physiological, pathological and pharmacological principles. These must have been considered useful, as the audience gradually built up to a peak of about 230 members. A key issue for me was familiarity with clinical problems, gained by daily attendance at clinical discussions in my own hospital, and I believe that this dual skill - clinical + basic science/laboratory testing - is an essential component for the success of such integrative sessions.
Some visits have been scheduled purely as lectures - I have judged these to be less successful - and in a couple the interpreter was less skilled in the joint clinical/English language requirements, again leading to less successful sessions. I continue to make visits, the last in 2005, where I was part of a symposium on quality control, and gave some hours of lectures to the final year students of one of the Universities on test choice and interpretation, in this case with greater emphasis on the basic principles of physiology etc.
The objectives of this program have been:
- To give the local people the opportunity to hear English language presentations on topics with which they are reasonably familiar, followed by a translation to ensure that they have understood the material. The format is a 1-minute English - 1-minute Vietnamese presentation and is heavily dependent on the skill and knowledge of the interpreter.
- To revise basic principles of physiology, biochemistry etc to the extent that these are necessary to understand the scope and limitations of laboratory testing.
- To encourage members of the audience to accept the need for proper integration of all available information about the patient's problem into an optimal overview for planning the best management strategy.
- To encourage local teachers and senior clinicians to set up and continue similar education sessions of their own to provide the continuing education necessary to medical graduates as knowledge and discovery progress, and as resources in Vietnam for health care increase with development and increasing community affluence.
Before she died, my wife accompanied me on these visits and actively participated in discussions of medical topics with the local audience members, besides warning me during talks if my enthusiasm led to too rapid speech. Many of the female members of the audience found it easier to talk to her than to me.
Analysis of the outcome is still incomplete, but I am certain that spoken English is now better understood by the audiences that it was 10 years ago - most of them laugh at the jokes before they are translated. How much this program has contributed, as against a general educational policy in Vietnam for foreign language acquisition, is of course impossible to judge. I understand also that there have been several local group discussions of problems, as mentioned in Objective 3.
Upgrading of local laboratory performance, equipment, quality control etc is an ongoing aim and some optimism is justified.
Finally, a word on cost - to me, personally, under $US 3000 per year, which means about $US 30,000 for the whole program.
To analyse the common features of these two totally different types of program, both of which appear reasonably successful in achieving their aims, I offer the following comments:
- In the recipient country(ies), there must be a sense of ownership of the program, with much of the definition of the objectives and mode of presentation being designed by the leaders of the profession in these countries, in collaboration with the donors
- These professional leaders must be widely respected in their own group and preferably also have acceptance in the higher political echelons, which facilitates acceptance by the students and makes travel, visas etc less troublesome.
- There must be a genuinely interested organizer/group in the country(ies) that are providing the educational input. It is preferable for these people to be familiar with the conditions and problems in the recipient areas, and personal acquaintance with the leaders in the recipient country(ies) is a great advantage.
- The program should deliver knowledge and skills appropriate to the recipient community, with encouragement to look towards future developments. There must be no suggestion of attempts to recruit the recipients to migrate to institutions in the donor country, which is a risk especially when students spend a significant period abroad in a training centre.
- Especial emphasis must be placed on comprehension. This involves, as appropriate to the circumstances, selection of students competent in English, provision of English language tuition for students studying abroad, provision of really skilled interpreters for short in-country seminars and lectures, and slow, distinct pronunciation of the English language components of the sessions.
- Mutual respect between the staff and students of the donor and recipient countries is an essential feature. When we from "developed" country institutions observe how much some of the leaders in the "developing" countries have been able to achieve with so little resources, such respect becomes sheer wonder.
I offer these two examples, and the general principles extracted from them, as a suggested framework for the design of "aid" programs in the future.