The Lancet Letter on the need for para-medics (2019)

To Dr Richard Horton

Editor-in-Chief of The Lancet

Dear Dr Horton

Thanks to the recommendation of a medical friend with whom I worked in Africa, I spent a part of my evening listening to your Dartmouth College lecture on PLANETARY HEALTH. I was apparently the 2,357nd viewer of your lecture at Dartmouth College on PLANETARY HEALTH Apr 20, 2017

You mention, among many issues, the need to look at Maternal and Child Health through an environmental lens. I was immediately reminded of my late father, Dr Edward Maclean Poulton, BA and DM (Oxon), MRCP (from Guy’s hospital), DPH, DCH. The Lancet was his favourite journal, and he read it until his death in 1994.

He worked 1967-1972 in Sierra Leone as the WHO Senior Advisor on Public Health. The new Minister of Health leaned across to my father during an official dinner in 1968 (the sort of function that my practical paediatrician father truly loathed) so say: “Dr Poulton, I want you to think up a really good prestige project for me.”

Dr Poulton’s response was to recommend that the minister should invest in main drainage for Freetown, and put up a large notice in Freetown’s international airport saying : ”WELCOME TO FREETOWN, the ONLY city in West Africa with MAIN DRAINAGE.” This was not the sort of “prestige” the minister had in mind; but some of your colleagues have been promoting public health approaches to MCH for many years.

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A few other comments might inspire or illustrate future editorials. You probably do not even remember that you mentioned these issues back in 2017, but here we go anyhow): Your passage on SPLENDID ISOLATION and Lord Salisbury was witty and very telling. History = propaganda.

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I liked your observation about the balance between AUTOCRACY and DEMOCRACY.

The reality about democracy, and its fundamental weakness - especially in tribal cultures such as the Middle East, or in Nation States like Nigeria, where the North is overwhelming, or like the UK, where the English outnumber the Scots, the Welsh and the Irish - is that Democracy = Demography.

So do tribes with high vaccination rates eventually gain power? Discuss !

A PhD subject in the offing….

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You speak (spoke) about the importance of IMPLEMENTATION and COMMUNICATION so that the work of scientists and academics may be better understood by other sections of society (with reference to BREXIT among other things).

I have always felt that the medical profession lacked a specific cadre of people: the medical interpreters. Europe, urban Africa, rural Asia: all have the same problem: after a doctor has delivered his or her verdict, together with a prescription largely written in Latin and often illegible, the patient departs with an obscure piece of paper and a mixture of fear and misunderstanding. The nurses are too busy to explain what the doctor said. The receptionist does not know what the doctor said. Sometimes the pharmacist will explain, but only if he or she is asked specifically, and only if they know what the prescription signifies in medical terms. WHAT IS MISSING is a kind and patient person who will sit down with the victim and explain what is on the list of medicines, why they are there, and how they should be used.

I have had people in Europe offer me medicines during a dinner party when my child took a bad turn (probably from over-eating), on the sole basis that the packaging had the word “children” printed on it: obviously a reference to dosage and not to content or intent. In Europe people are supposed to be “educated”!

In every African market there are street sellers sitting under the African sun hawking medicines by the capsule, and recommending the red one or the green one according to the taste of the customer.

The ignorance of ordinary people confronted by science (including medial science) demands more than simply Professor Brian Cox, wonderful though he is at explaining science to ordinary people. A whole new profession of para-medics is called for. “Development” has created an excellent upper crust, but no one is trying to link ordinary folks to those big bosses with diplomas.

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In terms of “implementation” I always insisted in my own various fields of micro-economics, peace building, urban and rural development, on the distinction between three approaches:

Pure Research

Applied Research

Action Research = “implementation” and “innovation” (applying recipes from one place for a new purpose or use) …. and then evaluating the impact of the implantation, learning the lessons and adjusting the methods to improve impact.

I have always been an active proponent and practitioner of Action-Research, but it is seldom recognized by the Academe. Indeed when I occasionally attend and participate in academic conferences, the “experts” and professors (who all know each other and who attend these conferences every year) seem quite put out to find that I know so much about my specific areas of expertise. Who is this interloper, this big mouth whom they have “never heard of ” and whose articles they have never read ….. because my priority is not publication. I have had very bad experiences with the “peer-reviewed journals” and academic publishers whose reviewers guarantee a closed shop that keeps people like me at arms’ length – journals that a small group of specialists run exclusively for themselves and which do not welcome action-research papers from outsiders - especially not from active field practitioners.

My father had the same experiences in the 1960s. In half a century, the barriers have not diminished. White Men in the North still control “knowledge” and other Black or Brown or Female scientists have to join the club and behave like the White Expert.

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I loved your 2017 final slide of the hand gun with a twisted barrel, which stands outside the UN building in New York. My own very modest late-career contribution to world peace and development has been in “micro-disarmament” which this sculpture so eloquently represents.

With very best wishes to you. The Lancet has been doing great work under your leadership. May you have a very successful 2020.

Yours Sincerely

Robin Edward Poulton

Robin Edward Poulton ChONM, ChROSC, UNSM, MBIM, MA (Hons St A), MSc (Oxon), PhD (Paris),

Docteur en Sciences sociales du développement

Managing Partner, EPES Mandala Consulting

Senior Fellow, UNIDIR Geneva (United Nations Institute for Disarmament Research)

President, V-Peace (VIPIS = Virginia Institute for Peace and Islamic Studies)

Professor of International Studies (affiliate), School of World Studies,

Virginia Commonwealth University 2002-04 & 2012-16