What is Family Medicine in Africa?
by Raymond Downing
For the last dozen years, my wife and I have been faculty members at a Kenyan university, helping to develop Kenya's first Family Medicine training program. Though we had worked for nearly 20 years in East Africa prior to starting, we were certainly not Kenyans. Yet we were hired directly by the university, not seconded from an NGO or American university. And since my work, at least, was primarily administrative, that meant I had to deal as a recipient with donors and other expatriate do-gooders. Some of them initially viewed me as an ally, because we shared western training and culture. But part of my task was to evaluate how their contributions would fit with what we had begun, and to coordinate them. If I suggested their contribution did not immediately fit, their view of me rapidly changed from an ally to a local person they needed to patronize. Sometimes I didn't even need to disagree.
Early on in my time as department head one of the do-gooders, a PhD expert from Europe, - in Kenya less than 24 hours - brought me to the local Club, bought me a Coke, and began grilling me: “What is Family Medicine in Kenya?” We were in the first year of training, struggling to implement a curriculum which was intentionally written in vague and general language to allow us to deal with his important question.
“Well… I don’t know. You see, in the US where I trained…”
“I don’t care about the US!” he interrupted. “What about here? What is Family Medicine here?”
“What I meant to say was that the general practice I’ve been doing here for the last 20 years is quite different from the Family Medicine I learned in the US…”
But the expert was not interested in what I learned in the US, or what I had done for the last 20 years. Or what Kenya needed. I clearly had inadequate answers for his questions. Simply to take the heat off myself, I asked him if he knew what Family Medicine was in Kenya. He did, and he told me: a picture of Family Medicine much like that in his own country.
He saw Family Medicine as primarily caring for outpatients, either those with chronic diseases, or with “undifferentiated illness” where our job was to make a diagnosis. Those ill enough to need hospital care would be sent to the hospital for the specialists to care for.
Then I tried to explain (in those early years I was always trying to explain something): first contact primary medical care in Kenya was done mostly by nurses and clinical officers. People sick enough to need hospitalization were sent to general hospitals run mostly by medical officers with no training beyond internship; there were then few specialists. If we as post-graduate trained Family Medicine doctors restricted ourselves to out-patient care, we would be referring the sickest patients we saw to be cared for by doctors with a lower level of training than ourselves.
But the European expert was not moved. “That,” he shot back, “is not our problem. We need to practice Family Medicine. Let the government sort out what happens in the hospitals.”
I remember being livid that he thought he knew what we needed after he had been in the country for less than 24 hours. Livid, but unable to show it, because I was now the recipient, and I was quickly learning that recipients are very careful about arguing, and never say no.
This story sets the scene for a dynamic very different from when I was trying to understand AIDS in Africa. For one thing, I was administering nothing then, only asking questions, listening, trying to understand. Now I was directing a program – and obviously should know what I was directing. With AIDS, there was a well-established literature that I could read; now the closest we had was extensive literature on primary health care in Africa – not exactly what we were teaching. With AIDS there was the public emotional story of Mbeki that I could engage with; now there was no public story as a sounding board for what we were doing. In other words, we were importing something new – and the university dean understandably told me: “You are the technical experts; you know your product. We will help you administratively, but you are the ones who know what Family Medicine is.”
Now if we were bringing in the first surgery program, that approach would make sense: surgery is the same worldwide, since anatomy is the same worldwide. But Family Medicine deals with families, with culture, and ultimately with the set of diseases most commonly found in those settings – and we were certainly not experts in that culture and those diseases. But – the response comes quickly from those advocates of a universal Family Medicine – surely the principles are the same: comprehensiveness, continuity, context-based bio-psycho-social care.
The principles do seem universal for the communities where the principles were developed: industrialized communities where chronic diseases make up a high proportion of the disease burden. Imposing them on a community where acute infectious diseases, maternal and perinatal conditions, and under-nutrition are common makes less sense. We could affirm the notion of a generalist physician, but felt that the notion of Family Physician as developed in the west could not be simply lifted from abroad and taught without modification.
I was caught. I was in the position to bring something in, but I didn't feel it was appropriate. My first step was to try to redo the product, make it more compatible. So I did what I always do when I want to figure something out. I wrote.
I first began to reflect on Family Medicine in Africa long before I started working in it. When I heard in the 1990s that some mission hospitals wanted to introduce Family Medicine training, I could not see the connection between the way I was trained and the health problems I was confronting in Tanzanian and Kenyan mission hospitals. But I did see the need for doctors to have post-graduate training beyond internship. When those missionaries working together with Moi University invited me to share some thoughts at a planning meeting in 2000 convened to advance the development of Family Medicine training in Kenya, I agreed.
The source I relied on to raise questions and suggest some alternatives was Maurice King's 1966 book, Medical Care in Developing Countries.[i] I had long been drawn to King's analysis because it seemed so logical to me. He had developed 12 axioms as guiding principles to follow in designing medical care in countries that had only recently been released from colonialism. The subtitle of his book underlined his major premise: “A Primer on the Medicine of Poverty”.
By using some of those axioms, and comparing them with some of the accepted principles of Family Medicine such as comprehensiveness, continuity, and bio-psycho-social care, I was suggesting that we needed other models for Family Medicine than the one designed mostly for chronic disease care in industrialized countries. But, in retrospect, it was not helpful to underline poverty as the "main feature determining" the “pattern of care” that King wrote about.[ii] Being aware of poverty is important in designing any health care system, but it is not Kenya's only reality today – and Kenyans understandably feel insulted when outsiders assume it is. Kenya still has marked poverty: some one half of its people live on less than $2 a day. But there is also a great deal of wealth in Kenya, meaning that the more important dynamic today is inequity. And because there is wealth in Kenya, both monetary and intellectual, why are we outsiders still trying to come up with the models to solve Kenya's problems?
But I was, then – though I should have known better. Several years before this I wrote a book on my experiences in "poverty medicine", two-thirds of which took place in Africa. I sent the manuscript to Fr. Laurenti Magesa, a Tanzania priest, and he offered some very kind comments. Near the end of his comments, he wrote, "I kept asking myself as I read: How can medicine incorporate itself into the African understanding of life as a unity of mind and heart, mind and body, individual person and society, humanity and the cosmos? What elements in the African experience of disease can help make medicine not only a curing experience but also a healing one? Can medicine in Africa cease to be looked at as "poverty medicine", with the unintended negative connotations of that phrase, and just be seen as medicine in Africa?" Why, he was asking, of all the defining characteristics of medicine, should poverty be the defining characteristic in Africa?
This piece was originally published in the collection "Global Health Means Listening".
Raymond Downing is an American medical doctor. After medical school and internship in New York City, he studied Family Medicine in Knoxville, Tennessee. Then he and his wife, Janice Armstrong, also a Family Doctor, opened a government-funded Family Practice clinic in a rural Appalachian county north of Knoxville. After seven years there, they and their family of two children moved to Eastern Sudan to work in primary care in a refugee settlement for three years. Following that they spent four years at a Mennonite mission hospital in Tanzania, and in 1993 they moved to Kenya. Downing worked for a year as Medical Coordinator in the New Sudan Council of Churches, with frequent travel to Southern Sudan. In 1995 he and Jan moved to western Kenya to work in a Quaker mission hospital. In 2001 they returned to the U.S. to work with the Indian Health Service on the Navajo reservation. They returned to western Kenya in 2004 to serve as Lecturers in Family Medicine at Moi University School of Medicine in Eldoret, helping to establish the first Family Medicine program in Kenya. They both continue to work there.
[i] King, M, Medical Care in Developing Countries (Nairobi, Oxford University Press, 1966).
[ii] Ibid, Preface.