Tropical medicine in Liverpool
Declan O'Regan takes an intensive course and finds that his Western health concerns undergo an adjustment
We were led up some narrow stairs to the "snake room." It was dark, steamy, and rather too intimate. A dozen students were quietly sweating as the curator introduced us to his adopted family. Stacked from floor to ceiling were vivariums full of the most poisonous snakes from around the world. Each of them seemed to hiss, spit, and rattle in my direction. Some of them had coiled up for a postprandial snooze, while the more nimble ones slithered serenely around their cages. While the curator explained to us the delicate process of milking the venom from these fellows I glanced to a noticeboard on the back wall. A rather weathered sign explained what to do in case the unthinkable happened: "... following the bite, the victim is to ring the alarm bell. A senior member of staff enters the room, catches the snake, and takes the victim to a chair..." Below the notice were what appeared to be two adapted golf clubs clipped to the wall, which, I presumed were to facilitate the "catches the snake" bit. It was not a moment too soon that we retreated for a well earned coffee.
A long tradition
This was one of the more memorable diversions that I experienced during my three month expedition to Liverpool to study for the diploma in tropical medicine and hygiene. Merseyside may seem rather distant from the equator but for over 100 years the school of tropical medicine has been at the forefront of research into tropical diseases. At the end of the 19th century, when the thriving docks received goods from throughout the empire, mariners frequently returned with untreatable fevers. In 1898 Sir Alfred Lewis, a prominent shipowner, founded the school, which was to be the first of its kind in the world. In the first 15 years the school organised 32 expeditions to the tropics, including Sierra Leone, the Congo, and the Amazon.
Groundbreaking discoveries
Its most famous alumnus, Sir Ronald Ross, won the Nobel prize in 1902 for discovering that malaria is transmitted by mosquitoes. In more recent years the school has been closely involved in programmes to control sleeping sickness, meningitis, and onchocerciasis, as well as in research on novel DNA vaccines and the use of genetically engineered mosquitoes. The school is also an important producer of antivenoms, with the assistance of a few Welsh sheep, for use both in the United Kingdom and around the world.
Students from all parts of the globe
The diploma course is tailored for those who are medically qualified and either need some intensive preparation for working in developing countries or have trained in the tropics and need to update and broaden their expertise. On the first day, we crowded into the lecture theatre and nervously introduced ourselves. Around half the students were European, and the rest came from countries all around the world. There were people of every age and seniority, from newly qualified to nearing retirement, as well as those who had only spent an elective in a developing country to medics with a lifetime of tropical experience. Many of the European students had spent short periods abroad but had soon felt out of their depth and poorly prepared for what awaited them. Some had been faced with large scale refugee situations or having to deal with epidemics and had to ask themselves, "Where do I start?"
The school is an important producer of antidotes to snake venom
An intensive curriculum
The course itself was an intensive mix of lectures, seminars, and practical sessions. The lecturers all had extensive experience of working abroad, and many participated in ongoing clinical trials in the tropics. Although time was often short, many of the speakers had a rich source of anecdotes to keep us amused while we tried to remember ever more complicated life cycles. In the laboratory sessions we mastered the art of staining blood films and preparing faecal smears, and whiled away many afternoons counting exotic ova and cysts. There was also a strong element of entomology, and, by the end of the course, we could distinguish a female anopheles from a male culex with our eyes shut. Some of the most useful sessions, however, were the afternoon seminars. Here we would be given a scenario such as managing an epidemic of diarrhoea, or reducing the number of perinatal deaths, and we would divide into groups and try to thrash out how we would set about it. The groups would include nurses and midwives from developing countries who were studying for the certificate course.
Practical application
The first reaction of a Western trained medic would be to rush in with his stethoscope and set up clinics, organise investigations, and arrange interventions. But towards the end of the course we came to appreciate the value of taking a step back and assessing the problem in consultation with the people affected. Organising fresh water, sanitation, supplies, and other public health measures invariably take precedence. Then you can begin to set further priorities and coordinate a plan to achieve them. The stethoscope is best left in the rucksack, at least in the initial stages. Indeed, it is probably better to take a shovel if latrines are in short supply. I had never before encountered the design classic of the ventilated improved pit latrine before I went to Liverpool, although we had to venture into deepest Wales to see an experimental double vaulted model in action.
Conclusion
The burden of illness beyond our shores is frequently relegated to the small print in our undergraduate training. This course makes an excellent foundation for those who wish to work in developing countries in a competent and sensitive manner. It puts our parochial health concerns in perspective while reminding us that there is still much that appropriately trained volunteers can offer.
Declan O'Regan, medical senior house officer, Chichester
studentBMJ 1999;07:394-436 November ISSN 0966-6494
