National Professor Nurul Islam Memorial Lecture 2015

February 15, 2015

“A friend to those in need”

It is an honour and a privilege to be invited to deliver this second annual National Professor Nurul Islam Memorial Lecture, held in tribute to one of the great leaders of our profession.

In this lecture I will highlight the life’s work of National Professor Nurul Islam, especially his commitment to human rights, health education and tobacco control as a physician, teacher and research scientist. I plan to draw parallels from the life and work of Professor Islam with the work we are doing as family doctors today in the South Asia Region and around the world, and provide some examples of WONCA’s global activity.

I never had the opportunity to ever meet National Professor Nurul Islam and so, in preparing this oration, I am indebted to Mr A I Islam, Professor Islam’s son and the Chairman of the Board of Trustees of the University of Science and Technology Chittagong, here in Bangladesh, who provided me with some of the writings of Professor Islam, and to Professor Kanu Bala, Chairman of this WONCA South Asia Regional Conference, and Director of the Bangladesh Institute of Family Medicine and Research, who provided me with some of the images I will share with you during this presentation.

I have titled this oration, “A friend to those in need”. It is clear that Professor Islam, with his commitment to human rights and health education was devoted to ensuring that health care is available to all people, especially the most vulnerable, and that he spent his entire life, including his golden years when many others would have retired, working towards this goal.

National Professor Nurul Islam was born on 1st April, 1928, in Chittagong, Bangladesh. He trained in medicine in Calcutta. Like many successful leaders in medicine, he was a prolific author, writing 27 books and over 100 articles in international medical journals, as well as making contributions to national and international media publications. His writing is part of his enduring legacy.

In a paper written for the Chittagong Medical College Magazine in 1961 and entitled The Days Ahead, Professor Islam recalls the time before he was a medical student. “I was then a student of science. (My) future was yet undecided. A friend of mine took me to different places of interest in … Calcutta. Towards the end of the day we reached the Medical College Hospital. A gigantic gate, monstrous pillars with lions at the top, the broad stairs leading to the first floor, are all still vivid in my memory. (The) too many anxious visitors for the ailing hundreds within the four walls were at first sight terrifying. The next thought that crept in was nonetheless equally pleasing … here are the doctors with their lives dedicated … I wished I could be a doctor.

Professor Islam became a successful and respected doctor and researcher, and a leading public figure in his nation. His past students also attest that he was a remarkable teacher, as this image shows with a crowd of his dedicated students pressing in. With so many students clamouring for his attention, and hanging off his every word, no wonder he needed the megaphone.

Our teachers during our medical training and subsequent careers have influenced the sort of doctors we have become. As family doctors, we are all indebted to our teachers; our medical colleagues who have taught us how to practise medicine in our communities using a combination of “scientific knowledge and tender loving care”. Indeed this is the Latin motto of the Royal College of General Practitioners, and many other national colleges of family doctors, cum scientia caritas, “with scientific knowledge and tender loving care.”

Our medical schools shape our future doctors, and in so doing shape our health systems. Doctors are granted substantial privileges and resources by our societies. These privileges imply a corresponding responsibility to participate in improving health systems and training the next generation of doctors to meet the needs of our societies. While our medical schools have the capacity to influence health care systems, they do not always choose to do so. Some medical schools pursue research agendas and technological developments that have limited relevance to the urgent, unmet health care needs of the communities where they are based.

Social accountability involves a commitment by medical schools to direct their education, research and service activities towards the priority health concerns of the community, region or nation that they serve. Such responsibility to society should guide every medical school and permeate the scope of their activities. This is something Professor Islam also taught his students and demonstrated through his example.

Late last year I visited Cuba. In an extraordinary contribution to global health, Cuba’s Medical School of Latin America (Escuela Latinoamericana de Medicina – ELAM) over the past 15 years has trained 27,000 young people from disadvantaged communities in 65 countries to become doctors. It is clear that, while many wealthy nations source doctors and nurses from other countries to meet the health care needs of their populations, what they should be doing is following Cuba’s example and training more health care professionals than they need and making a net contribution to the rest of the world. If a small, developing nation like Cuba can make extraordinary contributions like this to humanity, why can’t other nations?

Cuba’s Medical School of Latin America is part of a global movement of socially accountable medical schools dedicated to training medical students to better meet the specific needs of the communities they will serve as doctors. The medical education provided in Cuba emphasises the importance of primary care.

It is through academic leaders like Professor Islam that many medical schools around the world have seen the light and found ways to make a positive impact, especially towards health equity. Our medical schools need to select students from among the members of marginalized communities in both urban and rural locations, and prepare all our medical students to work where they are most needed. WONCA is proud to support the socially accountable medical school movement underway around the world. We are also pleased to see a greatly heightened interest among many medical students in global health and primary care and the contributions we can all make towards health equity and universal health coverage.

Professor Islam once wrote that, “Medicine is a science with human understanding and warmth – selfless, dedicated and wise.”

WONCA was founded in 1972 by 18 colleges and academies of general practice and family medicine from around the world; 18 organisations with members sharing a commitment to improving the quality of life of the peoples of the world through fostering high standards of care in general practice/family medicine, and through respect for universal human rights. Bangladesh is represented in WONCA through both the Bangladesh College of General Practitioners and the Bangladesh Academy of Family Physicians.

Forty-three years later WONCA’s mission remains the same and WONCA now has a membership of over half a million family doctors in 140 countries around the world. WONCA’s membership includes all the members of our member organisations here today. The 500,000 family doctors represented by WONCA each year have over 2 and a half billion consultations with our patients. Two a half billion. That’s the scope of our current work and our influence.

But we need to do more. WONCA is an inclusive organization. We need to work to ensure that every family doctor, every GP, every primary care doctor, joins us in our commitment to deliver high quality primary care to our patients and communities.

We also expect our members to do their part and share our commitment to education and training and a commitment to quality care. And while we recognize that there are excellent family doctors in the community who may not have received formal postgraduate training in family medicine, and we welcome these doctors as members of WONCA, we believe that these doctors need to share our commitment to continuing professional development and continuing medical education. We also believe that all new medical graduates should receive formal postgraduate training before being eligible to practice as family doctors in the community. Every person, every family in every community deserves to receive high quality medical care from a well-trained and qualified family doctor. And this is why WONCA was established.

We also need to expand our commitment to the education and training of family doctors and quality care and primary care research to the nations of the world where WONCA does not yet have a presence, which includes some nations here is South Asia, especially Bhutan and the Maldives. This expansion of WONCA is one of my personal goals as president and it was wonderful last year to welcome family doctors from Bhutan to the WONCA family.

Why do we do all this? Because family medicine is important.

Because the evidence is clear that health systems based on strong primary care, which includes strong family medicine, are the most efficient, equitable and cost-effective.

Because strong primary care is the best way to improve the health of individuals, families and communities.

Because we believe every family should have a family doctor who the members of each family can trust for their medical care and advice.
Because family doctors and the members of our primary care teams are part of the social fabric of our societies and we work together to keep the fabric of health care together.

We cannot tackle health equity without addressing the health needs of people living in rural areas right around the world.

Last year WONCA released our new Rural Medical Education Guidebook which reinforces our commitment to ensuring we meet the health care needs of the 50% of the world’s population living in rural areas, as well as those in urban areas.

While our clinics may be different from country to country, what is important is the way we are the same – through our commitment to comprehensive, continuing, coordinated whole person care. Through care that is person-centred, and family and community-oriented. Through first-contact care, acute care, chronic disease management, prevention and health promotion. And through our understanding of the interplay between population health and the health of individuals in our communities.

One of the founders of WONCA was Dr Prakash Chand Bhatla from India, who once wrote that “Every national health program should involve general practitioners. Education and motivation of the community has to be done on a personal basis. And who is nearer to the community than the family doctor?”

Who is nearer to the community than the family doctor? As family doctors we need to be engaged by our governments and international health organisations in the planning and delivery of national and local health programs. Family doctors are part of their local community and have the trust of their local community and can be part of ensuring the successful delivery of health care programs, especially to the most vulnerable members of our populations.

Last year I had the opportunity to visit with our colleagues in the South Asia Region on three occasions. Over 25% of the world’s population lives in South Asia, many in dire poverty with limited or no access to health care, and WONCA is committed to supporting the developments in this region.

The image of primary care is challenged in some parts of South Asia. Many medical graduates seek to train to become consultant specialists and then subspecialise further, becoming what is called in India a superspecialist. This has skewed health care expenditure away from community-based primary care to high technology tertiary care. It has led to health care systems that result in huge inequities in health care access and outcomes.

This diversion of health care expenditure means that countries in this region are struggling with universal health coverage; the challenge of providing health care to all people of this region, and especially those living in rural areas. The national government of India, for example, has recognised at last that health care can only become universal through strengthening of primary care, and is working with WONCA and our member organisations in India to turn things around. It is a long process but centres of excellence like the Christian Medical College in Vellore are leading the way in providing excellent experience in community-based family medicine for all their medical students, and in providing postgraduate training in family medicine. I hope we will see the specialists in family medicine become recognized as the super superspecialists that they are.

There are those who say that family medicine has no real role to play in low and middle-income countries. Well in 2013 we blew that theory out of the water. Last year the Director-General of the World Health Organization, Dr Margaret Chan, launched WONCA’s new Guidebook on the contribution of family medicine to improving health systems. The guidebook includes a chapter from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many middle income nations including China and Thailand. And there is a chapter outlining the remarkable work that is underway across Africa to strengthen family medicine, especially involving WONCA member organisations within Africa supporting developments in neighbouring nations.

What these developments demonstrate is the need to strengthen the whole health care workforce, including family doctors, community nurses, community health workers, and traditional birthing assistants, and support us working together to deliver appropriate care to all people. People in low income countries still want and deserve access to health care, access to caring clinicians, access to life saving medications.

We also need to embrace the concept of reverse innovation. What can health systems in high-income countries learn from the health systems in lower income countries? It is something that each of who spends time working in another health system in another country learns very quickly.

It is also a lesson that was emphasised by another of our past WONCA presidents, Rajakumar from Malaysia, who once wrote that: “Experience in different health systems will make us better doctors and better human beings.” It was wonderful to travel with other visiting delegates yesterday to visit health clinics here in Dhaka and see the great work of our colleagues in family medicine here in Bangladesh.

If we are going to have an influence then we need skills in leadership. It is one of the reasons why WONCA is committed to supporting young family doctors around the world. WONCA has young doctor movements in each of the seven regions of the world, including the Spice Route Movement here in South Asia. WONCA has also introduced the position of a representative of young doctors on the executive of WONCA, and the first person to be appointed to this position is from the South Asia Region, the inspirational Dr Raman Kumar from India.

National Professor Nurul Islam was of course another inspiring leader. He demonstrated his leadership in many ways: as a founding member of the Pakistan and Bangladesh Colleges of Physicians and Surgeons; as founder president and founder vice chancellor of the University of Science and Technology Chittagong; as the chair of the first national AIDS committee of Bangladesh; and as the founder of national antitobacco organisations. His life work was also recognized through awards from many nations and from the World Health Organization, for his global leadership in tobacco control.

Through his example, Professor Islam showed that he understood the concept of service to the community and to humanity.

As family doctors we need to support the focus on the social determinants of health and ensure that those groups of people in our communities most at risk of poor health, the most marginalized, the most vulnerable, are not excluded from access to health care.

Every human being should be treated with dignity and respect. And as health professionals we should be leading by example.

Something Iona Heath, former president of the Royal College of General Practitioners in the United Kingdom and a great advocate for health equity, said a few years ago really struck a chord with me, “I believe that general practice/family medicine is a force for good throughout the world.”

Through my work in Australia and around the world, I am impressed with the commitment of family doctors and the members of their primary care teams to human rights issues. I am convinced that family doctors right around the world care about human rights; the basic expectations we all have about how we and our families and all people should be treated.

I am pleased that during my time so far as WONCA president, our organization has established two new global working parties, one with a focus on health equity, and another with a focus on the health of Indigenous peoples and minority groups, bringing passionate family doctors from around the world together, through the marvels of the digital age, to share experiences and develop global policy which we can use in our advocacy with the WHO and the nations of the world.

These challenges for our patients also test our own resilience. While we continue to innovate within our practices and within our communities to ensure that our patients receive the highest possible standards of care, it is critical that we also continue to innovate to find ways to support each other as well.

Many health care workers in primary care work under very difficult conditions, often without the resources needed to do their jobs. They work long hours and with arduous demands on their time. Their resilience is tested regularly, and many of our colleagues around the word feel unappreciated. And don't often hear the words thank you. This is why WONCA has established World Family Doctor Day, held on May 19 each year, to acknowledge the important work our colleagues do. And to say thank you for their commitment every day to providing health care to the people of their communities who trust them for their medical care and advice.

As doctors we can be proud of our profession. Each of us has a set of values and principles that determine how we behave as ethical medical practitioners. Like Professor Islam, each of us has the potential to be a role model for future doctors, and to contribute our own lasting legacy through the examples that we set in the way that we live our lives and the way we practise medicine.

Professor Islam once wrote, “The word disease must be understood in its true perspective. It is not malaria, dysentery, typhoid and tuberculosis. It is dis-ease. The World Health Organization defines health as a state of physical, mental and social well-being and not just the absence of disease. To maintain this “physical, mental and social well-being” is our responsibility.”

National Professor Dr Nurul Islam died aged 84 years on 24th January 2013 here in Dhaka in Bangladesh. He is deeply missed by his family, friends, colleagues, past students, the people of his nation and the many people whose lives he touched around the world. He has left a great legacy through his life’s work and an example that we can all follow as each of us strives to be the best doctor that we can be, and to provide the best possible care to each and every one of the people who trust us for their medical care and advice.

I wish to conclude with a final favorite quote of Professor Islam, taken from the writings of Charles Dickens, about what it means to be a doctor:
“They have to have
a heart
that never hardens,
a temper
that never loosens
and a touch
that never hurts.”

Like National Professor Nurul Islam, we can only succeed in our important work as doctors if we are truly, “a friend to those in need”.

Professor Michael Kidd
World Organization of Family Doctors (WONCA)
Dhaka, Bangladesh
13th February, 2015