A Time to Remember

by Alexander Todd

  The report of the Interdepartmental Committee on Medical Schools (the Goodenough Committee) reflected the growing dissatisfaction with many features of medical education at that time; the changes made as a result of it were smaller than had been hoped, partly because of the incidental effects of the National Health Service Acts. The institution of the National Health Service must rank as one of the greatest social advances in our history but, for a variety of reasons, its institution was bound to involve acceptance, at least for a time, of the main features of existing medical education and the structure of the profession, not all of which were desirable. The Commission was, therefore, faced with a formidable task which we completed in about two and a half years.

  In the course of our studies we took evidence from around 400 individuals and organisations and visited medical schools in the United Kingdom and in a number of other countries; we also examined the various systems of medical care currently in operation, from the highly centralised polyclinic systems of the Soviet Union and other East European countries, to the Kaiser Health Plan in California, and the rather complex hospital system in Japan. Our studies had their lighter moments. On questioning representatives of the Physiological and Anatomical Societies as to the amount of time which should be devoted to their respective disciplines in an undergraduate medical course, the only answer I could elicit was that each of them wanted no less time than the other. Again it was interesting to be told that the chairman of the General Medical Council in the United Kingdom and the French Minister of Health were both slightly worried about the possibility of Britain joining the European Economic Community. The one felt that Britain might be flooded with ill-trained doctors from France, and the other that France might be similarly flooded with ill-trained doctors from England.

  It was clear to me from the outset that recommendations made by the Commission would be of little value unless they provided an adequate answer to the country's need, not just in the immediate future, but for at least a couple of generations. We therefore had to develop a picture of a likely pattern of medical care in the future, and to use it in forecasting both manpower needs and the general pattern of medical education, which was sorely in need of review. The education of a doctor, originally little more than an apprenticeship in which the aspiring student 'walked the wards' with leading practitioners, has retained more of this character than most other professions. The Medical Act of 1858, which still largely dominated medical education when the Commission began its work, was drafted on the assumption that at the end of a few years' undergraduate training, the emergent doctor would be sufficiently competent in medicine, surgery and midwifery, to set himself up in general practice. This assumption, long since totally unrealistic, depended on the view that the essential object of the undergraduate medical course was to produce a safe and competent general practitioner. Not until 1967 did the General Medical Council make any substantial changes in this system of education, which, over the years, had militated against the institution of postgraduate training, and had consolidated the division between the consultant physician or surgeon practising in the major hospitals, and the general practitioner who was without access to beds, and professionally considered to be of inferior status. We clearly could not put matters right at a stroke, but, in our report issued in the spring of 1968, we set out a series of proposed changes (largely a distillate of the views we had received from those who gave evidence) which would, in due course, lead to the desired end. This is hardly the place to discuss these in detail, but, basically, we recommended reorganisation and broadening of the undergraduate curriculum, the introduction of organised postgraduate professional training for all specialities (including general practice) together with some changes in the existing career structure and the introduction of vocational registration.

  We devoted a section of our report to the problems of medical education in London with its twelve medical schools, and their associated teaching hospitals, for the most part located within a small area of dwindling population. Our proposals involved reducing the number of schools to six by a process of twinning, and the association of each of the new schools with a multifaculty institution. These proposals were violently opposed by the medical traditionalists, and by the then Principal of the University of London, and were therefore in effect rejected, although, with the passage of time, some parts of our ideas have been put into effect (e.g. in the case of St Bartholomew's Hospital, the London Hospital and Queen Mary College) and I have no doubt that in time more mergers will occur. I found it difficult not to be amused when, in 1979-80, the situation in London had become so manifestly unsatisfactory (as I knew it would if our proposals were ignored) that a new committee under Lord Flowers was set up by the University of London to examine it afresh. The solution proposed by Lord Flowers and his colleagues differed little in general principle from ours, save that they laid no stress on association with multifaculty institutions; like us, they proposed the pairing and amalgamation of the London medical schools, but they also recommended the closure of one of them (the Westminster), a recommendation bound to cause a storm.

  My own belief is that the Todd Report, had it been acted upon promptly, would have given a better long-term solution, but, however that may be, the Flowers Report has been attacked by the medical traditionalists just as ours was, even after the lapse of ten years during which conditions had further deteriorated. The failure to follow the recommendations of Todd or Flowers, or a distillate of both, will merely postpone and render even more difficult the inevitable reorganisation of medical education in London. It is amazing how ostrich-like our medical colleagues can be!

  It was not to be expected that the report of a Commission such as ours would be 'accepted' by government, for much of it dealt with matters over which government could have no control. Government did, however, accept our recommendation that new clinical schools should be instituted in the Universities of Cambridge, Southampton and Leicester, all of which are now in being, giving us the capacity more nearly to meet the growth of demand for doctors in the future. Despite suggestions to the contrary in recent public statements, I still believe that our estimates of demand will be in due course vindicated. Recent changes in the organisation of the National Health Service are also moving in the direction we suggested. In other areas, too, I am not dissatisfied with the progress made since our Report was published; there have been substantial reforms in undergraduate teaching courses, and postgraduate training has undergone much development. It is true that our views on the career structure in medicine have not yet found favour, but it is my own view that they will be adopted in due time; professions as long established and as conservative as medicine are invariably slow to move.

  Broadly speaking, the so-called Todd Report was well received, and had a considerable impact in the United Kingdom. Perhaps more surprisingly, it aroused considerable interest not only in Commonwealth countries in which medical education is mainly along British lines, but also in the United States where the pattern is different. The degree to which any of our ideas have been adopted there (if at all) is unknown to me, but I recall the great interest shown by professors and deans from many of the American medical schools when I presented our findings to them at a large meeting of their Association in Houston in November 1968. I found that there was much more on which we could agree than I had expected. But perhaps I should not have been surprised; medical education and medical practice are under the same pressures everywhere. Every new discovery in medicine creates a demand for medical care which did not exist before. This is a situation where invention becomes the mother of necessity, and the demand for more and more health care is insatiable. Under these circumstances all countries will inevitably be driven along the same paths in their efforts to deal with it, and the patterns of medical education will become more and more uniform as a result.

  During the 1960s I did a great deal of overseas travel, visiting and lecturing in many different countries. It was during this period that I first vis
ited Africa. In 1965 I was invited to visit Accra where my former pupil, J. A. Quartey, had become Professor of Chemistry in the University of Ghana. I was guest of the recently formed Ghana Academy of Science, and my visit was timed to coincide with that of Queen Elizabeth and the Duke of Edinburgh, so that I saw Accra very much en fete, living, as I did, downtown in the Ambassador Hotel. Admittedly, the festive spirit was not very evident among the rather silent and gloomy Russian technicians who seemed to make up most of the company there, but we had flags, fireworks, etc. Kwame Nkrumah was still in power, and I met him once or twice; I was not over-impressed for, although he seemed to me to be an astute politician and something of a demagogue, he had a rather low intellectual ceiling. As a result, he was a ready prey to the rather shady bunch of sycophantic advisers who were around him. He certainly had some foolish ideas. On one evening while I was there, a great banquet was arranged (for men only as I recall it) at which the Duke of Edinburgh was to be formally invited to be Patron of the Ghana Academy of Science, and I was to be admitted as an Honorary Member. On the morning of the day appointed for the ceremony I was breakfasting on the terrace at the Ambassador, when Joe Quartey arrived, accompanied by Professor Ernest Boateng who was, I think, Secretary of the Academy at the time, and who appeared very upset. He told me he had just come from Nkrumah, who had told him that he had decided that the Academy should become a much grander body, and that he should lead the way; accordingly he, Nkrumah, would announce at the banquet the creation of the Pan-African Academy of Science with himself as President, and ask the Duke to be Patron. Boateng, like me, thought that to do such a thing without prior international consultation would infuriate the other African countries, and that the Duke would certainly have to decline the invitation to everyone's embarrassment. We decided we had to take some action, but found that Nkrumah had already set off with the Queen to open the new Volta Dam; the matter had therefore to wait until the evening. Fortunately, between Nkrumah's return to Accra and the banquet, we got him to change his mind and the banquet went ahead as planned; no Pan-African Academy was mentioned, but it was a near thing!

  I greatly enjoyed that first visit to Ghana, despite the undertone of discontent with the regime that I found among the academics and other educated people. The people seemed gay and friendly, and the enormous market-mammies in the Accra market had to be seen to be believed. Apparently, the local inhabitants admire the physical proportions of these ladies as much as their business abilities, and find European women rather feeble looking. At the time I speak of, my friend Joe Quartey had a houseboy (actually a middle-aged man) who looked after Joe and his wife Patience in their house on the edge of the university campus at Legon, which is, I suppose, three or four miles from Accra. The houseboy, who had never been as far as Accra in his life, decided he would like to see the Queen, and so he set off early in the morning and walked to Accra to see the Queen perform some ceremony. He duly returned in the evening and resumed his duties without making any comment on his day's outing. The following morning Joe asked him if he had indeed seen the Queen. 'Yes,' came the monosyllabic answer.' But is that all you have to say about it?' said Joe. 'Huh! She no be big strong woman - no be proper queen!' Parts of Ghana are beautiful - I remember the great rollers coming in on the glittering white sands at Winneba, and the dense forests on the road up to Kumasi. While I was there, Nkrumah was busily building up the newly created Technical University at Kumasi, incorporating in it what had been a first-class technical and agricultural school (which I felt would have been more useful than the grandiose institution being developed in its place). At the time of my visit there was a bit of a row going on between the university administration and a student residence on the outer rim of the campus; in accordance with current happenings elsewhere, I was not surprised to hear that the residence was locally called Katanga and its warden Tshombe! Kumasi was an interesting place - quite different from Accra. Tribal feeling seemed strong, and the Asantahene was held in great respect as effective king of the Ashanti people.

  My wife and I visited Ghana on two later occasions, first during the military regime of General Ankara, and in 1971 in the period of civil government prior to the takeover by General Acheampong, when I gave the Aggrey-Fraser-Guggisberg Lectures. On both visits we stayed in the university's guest bungalow high up on the hill behind the main university buildings with a fine view over Accra towards the sea. During these visits the university was having student troubles, rather like its sister institutions in the U.K.; as usual, the basis of the protests and demonstrations was never very clear and, as far as I could see, there was no violence. I spent a couple of hours one day in the Union with the student leaders who had been complaining that they were never allowed to meet distinguished visitors. At the end of our talk, I asked what they were doing next, and they said they had an appointment with the Vice-Chancellor, Dr Alex Kwapong, in his office up the hill at the far end of the campus. As I was only going across the road to the chemistry department and would be there for the next hour or so, I suggested that, it being a hot day, they should all pack into my large black official limousine and be driven up to see the Vice-Chancellor. This suggestion was greeted with enthusiasm, and off they went. What I did not learn until that evening was that the students had arranged the meeting with the Vice-Chancellor to complain that he provided no transport for them from the gateway by the bus stop on the main road from Accra to take them up the half-mile avenue leading to the central university buildings where the main lecture rooms were! It is not, however, true (although it has been said) that, on the following day, a student demonstration was held accompanied by the chant 'Kwapong out, Todd in!' The Ghanaians are a friendly, hospitable and able people living in a country with great potential; it is sad to see them plagued by political instability and consequent economic disruption. One can only hope for better things in the future.

  On most of the trips made in the sixties to chemical conferences, Bob Woodward and I travelled together and our friendship became even closer. Indeed, there were times when our appearance together at symposia made us feel rather like a travelling vaudeville act. But the highlight of the decade was when Bob (in my view belatedly) was awarded the Nobel Prize for chemistry in 1965, and I was able to see him receive the prize in Stockholm.

  The 1970 Indian Science Congress was held at Kharagpur near Calcutta, and I was invited to be present at the Opening Ceremony performed by the Prime Minister, Mrs Gandhi, on 3 January, and to deliver a plenary lecture. By the time January was approaching I found myself with other commitments added to this - the dedication of the new laboratories of the National Drug Research Institute at Lucknow, and a mass of lectures and other engagements in Delhi and Bombay. My wife and I left London by air on 1 January but, on arriving over Dum-Dum airport at Calcutta the following morning, fog was so thick that the aircraft, despite cruising around for an hour or so, could not land. As fuel was beginning to run low, the pilot decided he must carry on. The end result was that we were deposited in Hong Kong, had some four hours in a hotel there, and flew back to Calcutta arriving in the small hours of 3 January. After a further two or three hours we set off again by road to Kharagpur, which we reached just in time for the opening ceremony. It is fortunate that I was seated behind Mrs Gandhi, for I am afraid I slept through most of her address, and indeed I was pretty whacked by the time I got through the formal lunch and delivered my own lecture. On the following day I had to attend the Congress meetings until we were taken off to Calcutta again to get a plane to Lucknow. As luck would have it, engine trouble delayed the plane and we arrived late at night in Lucknow only to be on parade again at 9 a.m. the next morning to dedicate the new laboratories of the Central Drug Research Institute, make a speech, have lunch, listen to the young men giving me an account of their research, and board the plane for Delhi. The pace was much the same in Delhi, and after that in Bombay where we spent about a week. I remember getting close to the point of collapse after about two days there; I spent an afternoon i
n my hotel room feeling very unwell and more exhausted than I have ever felt before or since; but I recovered, and completed my engagements according to plan.

  At the time, I put down my feelings in Bombay simply to exhaustion, but now I am not so sure. Early in March 1970 I was struck down by a severe heart attack in Cambridge. Fortunately I was taken at once to Addenbrooke's Hospital and really well looked after by my cardiologist, Dr H. A. Fleming, and the hospital staff, all of whom I knew well since I had been Chairman of Governors of the United Cambridge Hospitals since 1968. After emerging from intensive care, I was told I must stay in hospital and remain effectively incommunicado for about eight weeks. My diary was fortunately relatively empty at that time. My next major engagement was the Commencement Address at the University of Michigan and that could be, and was, easily postponed until 1971. Thereafter I was due at Durham in September 1970 as President of the British Association for the Advancement of Science, but I reckoned I would be fit in plenty of time to fulfil that one. The big problem appeared to be how to pass the time, since I was told quite firmly that I must on no account work. I didn't see how I was going to survive on detective novels and the radio, so I cudgelled my brains for an answer. I found it partly as a result of some comments by my friend C. P. (Lord) Snow - I decided to learn Chinese as a means of keeping my mind occupied. So I sent down to Heffers bookshop for such books as they had on the Mandarin dialect, and sent word to Henry Chan, a Chinese research student in my laboratory, to come along to see me to discuss the Chinese language. I am afraid it caused him quite a bit of concern, for the message was delivered to him 'out of the blue' on 1 April; but he did come along, helped me select the best texts, and I got under way. I found the exercise very rewarding. Chinese proved a very interesting language and, even if I did not come out of hospital a Mandarin scholar, I had learnt the rudiments sufficiently to enable me to build on them subsequently when time permitted. I fear, however, that I was too old to have any real hope of learning the 2000 or so characters necessary for reading even a newspaper. Still, with the increasing use of pinyin transliteration in modern China, the situation for the foreigner is slowly improving.