“Learn what you can, read what you can and don’t be an amateur. Don’t give up.”

By Olivia George

Quite accurately named a ‘lifelong visionary in global health’ by The Lancet, Sir Eldryd Parry, KCMG, OBE, is not only a true inspiration but also a delight to talk to, and I feel very lucky to have been able to interview him for this Global Health issue of Pacemaker. Aside from having undertaken years of important and interesting work in Sub-Saharan Africa, he is senior editor of Principles of Medicine in Africa (revised edition, 2004), and founded the Tropical Health and Education Trust (THET).
(For more information on THET see p 5 of this month’s Pacemaker)

1. Did your parents (both GPs) play a part in your decision to become a doctor? Who/what have been your greatest inspirations?
Yes – I had their example at home. They were selfless in their work: always available and very good clinicians. In one of my father’s books, which he bought long after he qualified (on the heart by McKenzie, who invented the venous polygraph) he wrote the names of patients he was seeing next to descriptions in the text – he was a very thoughtful physician.

The assumption was I would always be a doctor, but I wobbled for a time when at school. I loved my student years; Cambridge was quite difficult because I went at 17 and was a bit out of my depth initially. When I went onto Cardiff to do my clinical work I was academically and intellectually inspired by my professor of medicine, Harold Scarborough. He was one of three authors of one a standard physiology textbooks in the 50s, 60s & 70s, and he was an outstanding person. Inspiration is possibly slightly the wrong word – guide and pattern model is better. He taught me to think about mechanisms and across ideas, rather than in a very linear fashion.

Over the years different people at different times have inspired me, and now I’m inspired by committed younger colleagues.

2. It is difficult for British students today to imagine a life without the NHS – what was it like studying to be a doctor at the time of the naissance of the NHS?
I knew nothing different. The NHS began in 1948, the year I went to do my pre-clinicals, and my parents’ work from the inside didn’t change at all. In hospital we just worked; we weren’t aware of the NHS, as such, because the system was established and was working well. One of the great differences between then and now is that bureaucrats did not interfere, and there were no rigid time restrictions – no European Working Time Directive! The concept of lifestyle and time off didn’t arise. It was not very many years since the end of the war, when people had realized that they had to pull their weight in society, and we didn’t expect extras, didn’t look for time off, but just to do your job. It was no hardship; we were tremendously well looked-after as part of a small team. Of course, we had time off, and we played hard – being in Wales we played rugby. I still follow the rugby very closely!

3. How do you feel General Practice has changed over the years?
I was enormously privileged to grow up in a general practice with a father and mother who were absolutely devoted to their patients, and who were very good practically. My parents were well-read: they bought books and journals and didn’t depend on courses and external things being done for them. They learned for themselves and had occasional meetings with at the Cardiff Medical Society. They also learned when they called a consultant to come and see a patient at home; this was a rich opportunity for a GP. I wouldn’t say that general practice is better or worse today than it used to be, but there are substantial differences. The involvement of managers and datasets has changed things.

4. Were you interested in Global Health whilst at medical school? Did you see yourself spending so many years working abroad?
Yes – in a way. My friends and I were interested in medical missions. The father of one of my closest friends at Cambridge was a GP medical missionary, and my aunt had also been a medical missionary in India. It was assumed among the Christian group in university that you were going to be a missionary until proved otherwise! “Global health” as such wasn’t talked about. Work in an overseas country was either through the Colonial Office or through a missionary society. At that time people committed themselves for life, they didn’t say “I’m going for two years”.

5. Can you tell me a bit about your academic and clinical work in Nigeria, Ethiopia and Ghana?
From 1960 to 1963 I was a senior registrar – seeing patients, teaching and doing research in Ibadan, Nigeria. I was seconded from the Hammersmith Hospital where at my interview I was asked whether I’d be prepared to spend a year in Nigeria and I said yes. Six days after our marriage my wife and I left – we spent our honeymoon in single bunks in the Bay of Biscay! The work was so interesting and our research was very fruitful so that I stayed for two and a half years: I learned an immense amount of clinical medicine in that time. I returned to London well-equipped.

Five years later, during the Nigerian Civil War, I was invited to be Head of Medicine at a new university in the north of the country. There was no money in the kitty, but, because my previous work had gone quite well, the Medical Research Council and the Wellcome Trust were prepared to support people to work in my department. We started classical clinical teaching – history, physical signs, logical reasoning etc. But I also insisted on looking at the context of the patient within the society.

In a way the excitement was starting something new – providing doctors where they were badly needed and doing all sorts of interesting studies of diseases. Probably the most exciting thing was gathering together a group of outstanding young clinical scientists and letting them get on with it.

There were downsides inevitably; that in a different culture, it was hard if one was misunderstood, got things wrong or behaved as one should not have behaved. Making mistakes in someone else’s country is hard and I made plenty. It hurts because you’re a stranger in a strange land. I learnt some very painful lessons. On the other hand, the highs were very high and I absolutely loved my work.

The research side in Ethiopia absolutely blossomed and I was able to go back to the Hammersmith and ask for someone to come out and work with me to study the Jarisch-Herxheimer reaction in louse-borne relapsing fever. The young scientist who was sent out was David Warrell – Emeritus Professor of Tropical Medicine at Oxford University. Those were his first steps into medicine in the tropics.

The word privilege is a hackneyed word now but I still use it – it was a huge privilege to be trusted to do something for another country, to unlock some of the unknowns of medicine, to make things better for poor people and to see young students getting really skilled themselves and being able to carry on and teach others. I’ve had a wonderfully rich and fulfilling clinical, professional and home life.

6. I understand that you distinguish between tropical medicine and medicine in the tropics – can you explain this further? Do you think that the medical school curricula in the UK include these concepts adequately?
Classically tropical medicine was considered to involve certain parasitic diseases or what are now called the ‘great neglected diseases’ such as trypansomiasis, schistosomiasis, sleeping sickness, as well as malaria. We believed that what we were practising was general medicine in the tropics. I wasn’t the first to say this and others had already written in this way, for example Professor Michael Gelfand had written The Sick African in 1943.

To work in tropical medicine you need the skills and method of a really good clinician – if it is difficult to get a good history you need to be very skilled with your hands and your eyes. I don’t believe that you can understand medicine if you only approach it from a biomedical standpoint. You must consider the patient in the context of their culture, environment, home and seasons. All my teaching now aims to get this message across.

Medical school curricula are getting a bit more liberal, but it’s important that the students themselves push for more time for “global” health. Its only when students push that this will happen. And you should be pushing in Manchester!

7. What were your thoughts about your future and ambitions upon leaving medical school? How did these evolve as you became involved in work in Africa?
When I left medical school I wanted to be a physician – just that. I had TB when I was a clinical student so I spent a year in hospital and during that time I read The Lancet and I read up on physiology – I was preparing to be a physician! Many of us had TB in those days in South Wales.

8.In your opinion, what are the greatest global health challenges at the moment?
We could debate this all day long. If you look at it economically, it’s resources; climatically – climate change and its effects on the environment and therefore the security of food and of water. In education, the situation in Northern Nigeria is worse now than when we worked there, it has moved backwards. And in neighbouring Niger the number of babies per mother has increased there – currently standing at almost 8 – and this in a country marginal for resources, rainfall and food. There are appalling problems in countries of the Sahara – very poor education, especially for girls, high fertility, rapid growth of population, low rainfall, and then poor harvests and nearby conflict.

I don’t know which the greatest challenge is. But you cannot dissociate all of these challenges – economic, human, services – they are all inextricably interrelated.

9. What advice would you give to a young medical student or trainee doctor with ambitions of undertaking work or volunteering in developing countries?
Be enthusiastic – learn what you can, read what you can and don’t be an amateur. Don’t give up. Take a long view. Don’t be peripatetic. If you do some work for your elective, get fixed with that country and for those people – don’t jump to another country. Medicine is not travel; medicine is serving people in a different environment. The first time you go you’re a nuisance, the second time, you’re less of a nuisance, the third time you begin to cross a few boundaries. Be utterly professional, be informed, keep at the same thing and don’t give up. And recognize that it’s going to change you as much as you learn. We are different people from the ones who went to Africa in the first place. We were changed by our experience in the poor world. I often tell those who come and see me to be ready to be different. If you work overseas, people will probably see that you have courage and strength of character.

10. This year THET is celebrating its 25th Anniversary, what do you envisage for the next 5/10/15/20/25 years at THET?
THET believes in responding to the healthcare needs of a country according to that country, rather than being prescriptive – why do you think that this is so important?

I hope that THET will continue to be responsive not prescriptive and that it will continue to work with partners overseas on a wide range of issues for the long term. I don’t believe in short term development. One of the problems of being given grants is that often grants are for just a very few years. But that’s just the aperitif and there’s a four-course dinner to follow! You should be prepared to say “I’m taking a twelve year view”.

I would love to see THET still active and still attracting enthusiasts. The reason I started THET, with my wife and good friends, was that historically Britain had given help to overseas medical schools but this was no longer fashionable. Involvement in grassroots primary care became fashionable. But you can’t take one part of the health system and abandon another – so we wanted to return to historic responsibilities of supporting medical schools and healthcare training.

We didn’t go into medical schools and tell them what they needed, rather we had mutual discussions, asked them where wanted to go, what they felt were their weaknesses.

The THET philosophy is to work out how we can help our partners to reach their goals from a position of respect and humility and not from a position of pride and authority. This is what I hope is carried forward.

11. How do you keep up-to-date and how would you advise medical students to best do the same throughout their careers?
I read journals and books about development and history, and some development websites, and I read The Economist, The Times and the FT On Saturday. The FT is an outstanding newspaper on Saturday; one gets general reviews and reviews of important books on economic development. The great strength of The Times is the opinion columns – if you read nothing but the middle pages you are set up. And the sport is excellent. I would advise medical students to take The Lancet. It’s the best global health journal by far – the only one.

12. What do you enjoy doing aside from your medical projects?
Lots of things! First of all I’m a Christian – God gives me the joy of living. I love the Christian family and have a wonderful church. They don’t regard me as Sir Eldryd, but as the Eldryd who has been with them from a young age until now. I preach occasionally and give a homily in the early morning service (im too old fashioned for the young). I also play the violin, which I love, and we’ve got an allotment and a little house in West Wales – I love being there. I also like reading and writing and used to play a lot of tennis, although I play much less now!