International Cooperation Report
University of The Gambia:
Medicine Seemed the Place to Start

By Gail A. Reed

It’s just a sliver of a country, with a bit over a million people who live from peanuts, couscous and tourism. Your only reference point might be Alex Haley’s classic Roots, since the author’s ancestor Kunta Kinteh lived in a village just outside Banjul, the Gambian capital that is perched on the Atlantic coast of West Africa. The Gambia - like virtually all Sub-Saharan Africa - was the invention of colonialism, which artificially divided the Mandinga, Jola, Wolof, Fula and other tribes into “nation” states at the convenience of the colonizers. Consequently, the River Gambia, essential for the slave trade, became a British possession, surrounded by the French-possessed Senegal, an arrangement lasting nearly 400 years. The Muslim religion also swept down from the north, creating yet another cultural overlay to Gambia’s traditional African society.

Colonialism’s health legacy was dismal: the British left only two hospitals, and essentially no medical care “up-country” where most of the population lives, who continued to rely on the marabus who were the traditional healers. There were just four doctors per 100,000 inhabitants, clustered in the capital. Health indicators dramatically reflected this heritage: in 1994, just seven years after independence, 100 infants of every 1,000 were dying before their first birthday; 147 children died before they turned five, and maternal mortality was 1,050 for every 10,000 births. Life expectancy stood at 49. Malaria - the region's biggest killer - had become endemic, reigning over a host of infectious and parasitic diseases.

In 1994, Gambia’s new President, Dr. Alh. Yahya A.J.J. Jammeh - who first came to power by coup, but later was returned to office by election - made health and education priorities for his government, and the progress of young women a political commitment. Primary school became free for girls; dozens of minor and major health centers were built; a new hospital in Farafenni went up and blueprints developed for another in Serrekunda; and perhaps most important of all, the School of Medicine became the lead faculty in establishing the first university in Gambian history.

Dr. Yankuba Kassama: Nation-building is about sacrifice

Dr. Yankuba Kassama, Secretary [Minister] of the Department of State for Health and Social Welfare, recalls that President Jammeh made his first visit to Cuba in the late 1990’s, where he discussed his proposal: The Gambia needed a medical school to train doctors with a commitment to serve. As Dr. Kassama put it: “We needed to sensitize people that nation-building is about sacrifice sometimes. If (professionals) don’t stay, who will build this country?”

As a result, in September 1999, the first Cuban professors arrived in The Gambia, led by Dr. Arturo Menéndez, who was to become the School’s first Dean of Basic Sciences. The curriculum slowly began to take shape, with further assistance from Cuba, and from the World Health Organization. In 2005, The Gambia expects its first 15 physicians to graduate from the school, which has incorporated the Royal Victoria Teaching Hospital for study during the clinical years. This 540-bed hospital itself has undergone major changes to merit accreditation as a teaching facility, including complete remodeling of the accident and emergency services, blood bank, and ICU; plus a new pediatric wing, dental clinic, pharmacy, administration buildings, library and teaching labs and classrooms for the medical students.

	Fighting brain drain: The University of The Gambia also trains nurses like these young women.

Today, the School has an enrollment of 20 students in pre-medicine, 34 in 1st year, 18 in 2nd year, 6 in 3rd year, 16 in 4th year and 15 in the final year - 109 altogether, a good number of them women. The School also trains nurses and offers a public health degree. A total of 12 Cuban professors staff the school - eight in Basic Sciences and four in Clinical Sciences. Professors from Nigeria, Sierra Leone and The Gambia complete the teaching staff of 21 full-time professors.

Ousman Sanyang and Abba Hydara are two of the school’s projected first graduates. Their stories are not unique, and they help to illustrate the hopes, frustrations, and commitment of their classmates.

Ousman, who comes from the urban area of Serrekunda adjacent to the capital, had the opportunity to study in another West African country and even in the USA, but when he heard about The Gambia’s own school, he opted to enroll at home. “The medical school came into being because of the team of Cuban professors who landed here in September 1999,” he told me. “On October 4th, they started the medical school program in The Gambia. They were determined to make sure the school started, irrespective of the constraints and resource problems.”

History in the making: a University of The Gambia student in the classroom.

“The most important thing for the school at the beginning was that we had the will of government, of the students and of the lecturers. The facilities came later. The Cuban professors sometimes brought their own books, or would photocopy materials. We didn’t have Internet or even textbooks at first. We were sometimes frustrated. But our Cuban professors - who should have been put off by the lack of facilities, and even by the lack of chalk or erasers - just said ‘this is how we started in Cuba.’ They told us what was needed was commitment and determination, and that if we were committed, then they would support us. And so we got going.”

“What I’ve found is that practicing in a developing country is not easy. It has its limitations. The facilities for sophisticated diagnostic equipment often don’t exist, for example. But if we can make a diagnosis based on a detailed clinical history and a thorough physical examination - which is true for 85% of cases - then we even have an edge over students trained in Western Europe or the States. And that’s what our training concentrates on.”

Dr. Nestor Shivute, World Health Organization representative in The Gambia, notes that “we did not have medical doctors trained here before. They were trained in Western countries. And they tended to stay there, and only come home to visit….Yet, the most important resources are human resources. They are the key.”

One issue faced by the Gambian government - as in virtually all developing countries - is that government salaries are not on par with private sector earnings, and additional benefits have yet to be put in place. Dr. Kassama says special allowances for physicians posted in rural areas, plus additional benefits in the public sector, are among the incentives his ministry is reviewing in order to have a better chance to keep the doctors The Gambia is now training.

Fifth-year student Abba Hydara’s father is an accountant and his mother a rice farmer. He grew up in his grandfather’s compound of some 50 relatives in Brikama, not far from Banjul. Earlier he received training as a physician’s assistant and was certified to operate on cataracts. He said it was the presence of Cuban professors at The Gambia’s medical school that convinced him that “finally something was going to happen. I saw all these professors from Cuba looking serious, and the Cubans are no jokers! So it seemed the school was finally going to be set up.”

‘The Cubans brought their spirit,’ says student Abba Hydara, right, seen here with Cuban professor Joaquin García.

He gave up a more comfortable position with the health ministry to go to school, and dug in with the Cuban professors in pre-medicine and basic sciences. “The team of teachers was under pressure, especially because of language,” he noted. “But in the end, only one had problems, and the other eight stayed with us. They taught us never to take anything for granted; to study and be disciplined; and their system was very good for us since it includes almost weekly evaluations. That kept us on our toes.”

“But above all,” he said, “they brought their spirit. From the start it was clear that they were teaching to prepare us, to make sure we understood we had a responsibility to our people, to help them come out of the cycle of disease and poverty and ignorance. They never minced words about that. And so, from the beginning, we visited communities and families to get a sense of their problems, and to lay the foundation for ourselves.”

The students make a commitment to serve in the public health system (a practice known as “bonding”) for the same period of their studies - six years. While tuition is US$600 annually, all students until now have received scholarships either from the World Health Organization or from the Gambian government.

As minister for health, Dr. Kassama says his government has taken a close look at Cuba’s record in health and the kind of infrastructure it has developed, to see what is most relevant to The Gambia - where over 175 Cuban doctors are also serving in Cuba's International Comprehensive Health Program, primarily in rural areas. But also, he noted, “We’re seeing that to be a doctor is not a supernatural thing. You don’t have to be rich. You have to work hard to help your people, and that’s what makes a good doctor. But if you’re just working to enrich yourself, then it’s a futile (endeavor). That’s what we have learned from Cuba - selfless service instead of selfish. That selfish doctor should be history. We need to forget about that and move on.”