In colonial territories, the hospital has formed part of a system designed to look after the basic health needs of the poor. The public health need has been paramount, and the hospital service has remained relatively underdeveloped in relation to the size of the communities. It has provided a poor service for poor patients; whereas those patients who could afford to pay took their treatment in clinics at home and abroad.
This type of hospital for the poor has not been limited to underdeveloped territories, for it was basically the same in Britain before the national health service. However, there were important differences, specialists of high quality from teaching hospitals were readily available to practise in these poor institutions, providing good care often in poor surroundings. This process formed a basis for the great leap forward in the hospital service after the introduction of the national health service.
There was also none of the constant emigration of influential people including doctors and their families seeking medical treatment abroad, a tendency which has deprived the underdeveloped territories of the powerful voluntary stimulus to improve the service at home. Instead, we have found the hospital service run by busy general practitioners, too busy to provide a full service, and in most instances unable to keep up with advances in their field.
This system has allowed the development of certain attitudes in the service: poor patients grateful for poor service and resigned to no treatment; where life is cheap, and you go to hospital expecting to die; where lying in bed with another sick person is no indignity, but an opportunity; where other patients provide your basic nursing needs; and doctors are often revered, though, by the same token, they remain contemptuous of their patients and other staff. No doubt these attitudes are not as naked as they used to be, but we are the direct inheritors of this recent age. These problems are still to be uncovered today, particularly in casualty, where an overtired junior doctor may be asked to see a child who has been waiting 12 hours, a problem to tax the freshest and most senior person.
The health of a community must be safeguarded if it is going to be vigorous enough to sustain economic development. Health is not merely a measure of how little is wrong, but how a community reacts to it. In the West Indies, one sees patients accepting chronic stomach and urinary complaints as part of their natural life. They will come for advice when the disease is far advanced. It is true that one no longer sees a patient bringing his goadies on a wheel barrow for treatment. He may turn up when the swelling has only just appeared. But this illustrates how, with the increased education of the community, and the further development of communications, the community will expect more to be done for their health. How is a newly independent and underdeveloped territory to meet the challenge of maintaining and improving its health services, which are so vital if the community is going to develop? The answer lies in the proper development of available funds:
(i) The health service will need expanding, with a large capital outlay. In Barbados, this has already been partly achieved by the recent completion of the new hospital building. However, the services this provides at present will need expanding with further capital outlay, if we are to attempt to keep pace with the needs of the expanding community. With the increasing restriction on immigration abroad, and the ever increasing cost of medical care everywhere, there will be a further demand on the services at home, and more stringent demands for its improvement as the mere informed section of the community are forced to seek their treatment at home.
(ii) There must be a sufficient recruitment of specialists, and junior doctors, and of nursing and ancillary staff. Each of these sectors provides its special problems, which cannot be managed by the laisser-faire and crisis measures at present in practice. It must be remembered that all trained grades of hospital staff are short all over the world, and the developed countries will always be able to offer more in terms of salaries. Thus, an underdeveloped country has to compete on other levels than that of salary. We must remember, then, two things. First, if other things are nearly equal, people like to settle at home. Also, there are two aspects to a job: money and interest.
(iii) Thus, we will have to stop relying on expatriates. They make for one of the real problems of our colonialist society, since we have been brainwashed enough to believe that the misfits and second rate people whom one mainly sees in the colonial territories are better than anything that can be produced from the native soil. Also, there is the very clear economic reason that there is often a lack of continuity, and that the salaries paid represent a constant drain of money abroad, without any real reciprocal trade. I can imagine no developing country, or developed country for that matter, which can allow the constant export of significant amounts of money. Developing countries have found over and over again that there is no shortage of talent to be trained, but that there is a real difficulty in keeping such people when they have been trained in the developed territories. Why is this? I believe that it is due rather to a failure to create opportunities at home than to lower salaries. There is no point in someone, who is interested in his work, doing a job where there is insufficient room to manoeuvre in terms of equipment or to reach the top of his profession.
(iv) Therefore, there should be an expansion of the number of consultant jobs available in the hospital service, so that our newly qualified doctors can see the opportunities that lie ahead, rather than flee dispirited to another country, or into general practice. This expansion will also allow the people in the service to take an interest in their work, and where possible embark on research, rather than be in a state of constant overwork and feeling put upon.
The expansion in the service will also allow for gaps due to leave or to sudden death, instead of the crisis measures now in practice, which usually mean the importation of someone from abroad with all the usual expenses for only short periods of service. Where is the money to come from for this expansion of staff? In Barbados, an increase of six consultants would cost about $60,000 dollars a year in terms of salaries, which if it increases efficiency and allows the saving of the usual crisis expenditure, is justifiable especially when compared with the noted increase of recurrent expenditure in the hospital service in the past year, which has been to the tune of $1 million.
(v) An expansion of the top grade of staff would allow a clearer view by both the administration and the junior staff, of anticipated shortages and also provide a sufficient breathing space to allow planned training to occur. It would also allow room for the development of a continuity of interest, by the provision of short term scholarship opportunities abroad in certain specialist fields. In a small and developing society, we cannot hope to command the economic resources and technology required to carry out the research programmes needed to keep in the forefront of medicine. Therefore, we should be constantly sending people out to bring back what is going on at the ever- expanding frontiers of medicine.