France as a colonial power was concerned about improving the health standards of native populations as this was a requisite for overcoming their statute of underdevelopment. This was achieved through the work of the Colonial Army Medical Corps over a seventy five years period of time.

As a rule, young colonial physicians’ first and often second assignments were to medical posts somewhere in the outback where they had to be general practitioners : they were there entirely on their own without any possibility of resorting to a fellow physician.

At the turn of the century their conditions of life there, were quite a change for them, as these were terribly precarious ones. They were strongly advised to keep being unmarried but later on, with the availability of better conditions of life, this advice became obsolete. By the time of the second world war, family life there was deemed possible and even desirable.

Duties were entirely different according to the assignments : those of physicians who held a post in a local hospital were different from the ones of their colleagues who were assigned to run a Mobile Health Unit in West Africa. But, whatever the assignment, the presence of native aids whose help was absolutely essential to carry out the duties was a permanent feature for them all.

An assessment of the activity of these physicians shows that this has been a very constructive endeavour with the implementation of the most efficient methods to improve local populations’ health standards.

CONDITIONS OF LIFE

Upon his arrival in the capital city of a territory a young physician had to stop over there for a short official and formal visit : after being appointed to his post he moved on and reached his posting. Adventure started with the discovery of what the outback looked like : deep forest, savannah, sahel or desert. Finally he arrived at his post riding one of the locally available means of transportation such as a grit blowing train, a horse or a camel back, a truck, or with a dug-out...

For each of them, their first contact with this first post was a moving experience.

Recollections are identical all over the world :

Upon arriving in the Thai Country in North Tonkin in 1935 "I had the feeling that a mystery... had to be revealed". To get a full and clear understanding of the situation one should be reminded that this young man was travelling on his own on horseback with his personal belongings in small packsaddles and that he was due to be posted far away from the world he was part of, for a two year-long period of time.

At the same time In Northern Sudan around Timbuktu: "The desert is silent, nothing is moving, there is no smell and nothing ever changes. The horizon line looks always the same. This everlasting sight is a real knockout and the sunlight will make it really wonderful".

Upon his arrival, this incoming medical officer was introduced to the colonial administration representative who was known as "le commandant de cercle" (Head of the department in French Equatorial Africa, AEF) as in he was in charge of supervising the smooth running of a district. While he was on assignment there, for all administrative issues which he had to address such as the management of the health facility, the management of allocated funds, this medical officer who was no more under the command of the military, had to report to this civilian administrative authority.

He also got acquainted with the other four or five Europeans who lived in this small town : a judge, a veterinarian, a missionary, a sheriff, some shopkeepers and of course native notabilities and chieftains as well.

Let us not linger over the description of his lodging. Up to 1946 it was not any better than an enlarged African hut with a thatched roof, adobe walls, a dirt floor without any utility such as running water or electric power.

A refrigerator was a well appreciated convenience but it was working with kerosene and its wick had to be precisely adjusted. Electrical power generators started to be available around 1948 but not in all places but they were working only for a few hours at night so that kerosene lamps had also to be used. But finally one could get accustomed to this precarious settings.

An overseas tour of duty was two or three years long but during the Second World War some had to remain posted in the same place over a seven years period of time.

FAMILY LIFE

Whenever she escorted him, the physician’s wife provided her husband with valuable moral supporting as much as her personality enabled her to adapt to loneliness, which she could sometimes feel difficult to bear, living among people whose mores, customs and language were different. An heterogeneous European microcosm nearby resulted most of the time in a friendly bunch of people who would socialize nicely. But it could also sometimes wind up in a situation of conflict as climate could be responsible for psychological disorders among the ones with weak constitutions.

In everyday life his wife had to care about hygiene at home which was of the utmost importance in these countries : she had to check that their house was clean throughout and she also had to look for any possible hole in mosquito nets. She watched after a good maintenance of their beddings which were often spoiled by perspiration and she had to make sure that food and water were safe. Whichever place it was coming from, water had to be filtered, for all purposes including body washing. In Sahelian regions in order to avoid dehydration during the dry season, the air surrounding babies had to be humidified by hanging a moistened cloth very close to their cribs with a draft of air passing through. Despite the utmost possible care many European children have been unable to make it to France.

Some wives used to escort their husbands while they were doing rounds which sometimes stretched over two hundred or two hundred and fifty days a year, which in the nineteen thirties had to be done quite uncomfortably.

In spite of all precautions which could be taken, bouts of malaria were not rare, episodes of diarrhea or even of dysenteries happened frequently as well as miscarriages. Quite often, wives prevented their husbands from imperceptibly indulging in heavy drinking or other depravities because of depression and isolation.

MEDICAL ACTIVITIES

In the early days, in all parts of the world, all medical posts had versatile activities as they had to divide their activities between outdoor and indoor duties. Later on, but only in Africa, a special department to achieve the control of major endemic diseases was set up.

This is how in 1917, in French Equatorial Africa, an incoming physician could be assigned :

– Either to the Health Care Department : he was posted to a medical post in a district with a sedentary or semi-sedentary activity.

– Or to the Major Endemic Diseases Control Department which at first was in charge of controlling the Sleeping Sickness. This occupation involved a lot of travels which had to be done according to a schedule of screening and of vaccination which had been decided upon well in advance.

In the mid nineteen thirties the same pattern became available for French Western Africa (AOF) and was very quickly implemented.

As early as 1944 as their number had increased, these Mobile Health Units could start controlling other major endemic diseases such as leprosy, onchocerciasis, treponematoses, malaria, endemic goiter, malnutrition.

Over the years, there has been a considerable improvement of these conditions of work with better means of communication and transportation, with the availability of medical evacuation, and also with scientific advances.

PHYSICIANS ASSIGNED TO MEDICAL ASSISTANCE

At first, the designation of this Health Care Service was A.M.I which stands for "Assistance Médicale Indigène" which means "Health Service for Natives". It was later changed for A.M.A "Assistance Médicale Autochtone" meaning "Autochthonous Health Service".

Under the authority of the Director of Public Health who was posted in the capital of the Territory or the Colony, this physician started running the medical facility and the other medical installations of the district he had been assigned to. He introduced himself to the staff of health professionals who were in office there :

– One or two "auxiliary physicians" who had been trained in a medical training institution
– A few medical technicians with : male registered nurses who were either civilians or in some instances military nurses.
– Locally trained male nurses, who were often devoted and skilled personnel.
– A locally trained midwife.
– Nurses’ aides, unskilled workers, drivers.

This medical facility generally included :

– An outpatients’ clinic with a wound dressing theatre, a medications shed and a small biology laboratory.
– One or two inpatients wards.
– An operating theatre which was a closed room with the highest locally available standards of hygiene. The sterilization premises adjacent to it.
– A maternity which sometimes had to be built.

A motor vehicle which could be driven off tracks was available. In the early years whenever camel or horse back riding was unavailable, he had to walk which in pidgin French was "prendre le pied la route". He could also ride a palankeen in Asia, a tipoye in Africa, a filanzana in Madagascar which were the means of transportation for chieftains. The physician who was a young and good walker used them only when needed for prestige purposes.

His comprehensive training in tropical medicine at Le Pharo gave him the availability to take on the responsabilities of his assignment, with a versatile professional activity.

– As a general practitioner he had to be in the outpatients’ rooms very early in the morning as there were around one hundred patients who were already waiting. The most experienced nurse would sort out for the physician’s clinical examination the most serious cases or the ones which he had not been able to diagnose.

– Whenever there was no Mobile Health Unit, he also had to make rounds in the biggest villages of the district and see outpatients. These rounds which were made on a regular basis enabled him to vet the activity of the nurse in charge of this rural clinic, to supply him with medications, to address all pending issues and to care for the patients the nurse had already selected for him to examine.

– As an attending physician he had to care for all inpatients, and be informed of traditional ways of healing. He had to use wisely the therapeutic means he had been supplied with, also bringing to patients a comforting human contact.

– As a biologist he had to check the accuracy of the results of tests which had been carried out by health professionals trained in the field of biology such as major endemic diseases control personnel. He also had to do on his own those which required his skills (hematology, parasitology).

– As a surgeon he had to carry out emergency procedures. While attending "Le Pharo Institute", he had been taught some basic procedures of reduction and immobilization of fractures, of incision and ligation, of tooth extraction and he also had been trained to perform some more complex procedures such as amputations, caesarean section, tracheotomy and cure of strangulated hernia. From 1950 onward with better means of evacuation it became possible for those who were not too keen on surgery to refer their patients to larger and better equipped medical facilities.

– As an obstetrician and a pediatrician he was called whenever a delivery was difficult and this occurred quite often considering the high fertility rate of African women.

– As an occasional forensic scientist he could be summoned by court to carry out autopsies which constituted later quite sad and unpleasant recollections.

– When no veterinarian was available he had to check food supplies, mostly meats.

– As a manager he had to make use of the funds which had been allocated, to look after the buildings’ maintenance, to make regular medical and financial reports and rate the auxiliary personnel.

– As an epidemiological sentinel he had to give the alert whenever the mortality rate suddenly raised.

– As a community member he could be involved in social activities or he could also start a new one such as a sports club or a library...

Whenever a fellow physician of another district happened to pay him a visit they could spend long hours talking about their work, about some difficult medical cases, about the failures they had suffered but also about their successes.

THE PHYSICIAN ASSIGNED TO A MOBILE HEALTH UNIT

Upon his arrival the procedures were the same as those of the physician assigned to the Medical Care Service : after being introduced to his staff, he had to pay a visit to the local notabilities and to his fellow physician of the Medical Care Service as, most of the time after 1946 these two different health facilities were posted in the same city.

Before his arrival he had been taught at the Muraz Centre in Bobo Dioulasso, Burkina Fasso how to lay out his scouting rounds and he also had received some training in the fields of Tropical Ophtalmology and trachoma at the Institute of Tropical Ophtalmology and in Leprosy at the Marchoux Institute, which were both in Bamako, Mali.

His duties were different from those of his colleagues of the Medical Care Service. His field of action was much larger as the territory was divided into several districts which were sometimes as large as ten "metropolitan departments" in France. All People in this district had to be visited at least once a year. There was always a young colonial physician at the head of this health unit who had to follow the instructions which he had been given at the Muraz Center.

Nothing was left to improvisation. For instance the smallpox immunization program of the district which had been scheduled to be carried out over a three years period of time was now in its second year, and the one for yellow fever immunization which had been scheduled over ten years was now in its fourth year... Patients were diagnosed in villages which were scoured one after another in every subdivision of the district.

The methods of work. which were used there had been instigated by the Jamot* doctrine which had been set up in detailed technical memorandums, and their implementation became everyone’s responsability. One had to adapt oneself without any possible hesitation or delay to any of the most various embarrassments of this large continent After scheduling his rounds the physician had to report to the administrative authority (commandant de cercle) who was the only one who could decide on backing up his program and also on having official announcements made in advance.

These rounds were usually two or three weeks long. After being paid these health workers took a well deserved rest during the first week of each month, and cared for purchasing millet, sun dried fish and spices to feed their families. Then they had to leave home again until the end of the month. They worked every day even on Sunday without any break, starting at dawn in the morning until the last person had been screened.

A small team, in charge of "propaganda", prepares the ground for the prospection team. The populations must be explained what is looked for, why they have to be disturbed in their daily routine, why must everyone be seen, and what has to be done to prepare for the arrival of the team. The village people will come, one family after the other, the father leading, his wives following according to their rank, together with their children.

The departure of the itinerant team takes place in the early morning. The air is cool and light. A scene not to be missed is the incredible amount of material loaded on those trucks : cases of medicine, metallic chest where archives with census notebooks and lists of patients to be seen are stacked, boxes with kitchen paraphernalia, bags of rice, onions, cases for the consultation on the main square, and sitting on top of all that, the nurses !

Upon their arrival all their equipment had to be put in sheds which had been supplied by the village chief. Each member of the families who had reported for this medical screening was examined in a secluded booth. Emphasis was made on looking for swollen lymphatic nodes as they could be a symptom of sleeping sickness, on finding leprosy spots or onchocerciasis cysts which heralded possible river-blindness in the forthcoming years. A little farther on, smallpox and yellow fever vaccines are prepared and administered. As it was quite impossible to go through a village without treating other patients, a sort of consultation fair was held on the village square, where wounds and bumps could be care for. Whenever a really very sick individual was found he had to be taken along with the health team to be cared for in the hospital.

This was how they spent their time. Suddenly one could hear a microscope technician calling out "There is a Trypanosome here !". Every one wanted to check. A lumbar tap was performed with a cell count and then it had to be explained to the patient’s relatives that he had to be taken to the Sleeping Sickness Hospital where he would be cared for and fed for free but that it would be nice to have his mother or spouse or sister escort him so that there would be someone who could look personally after him and comfort him.

By the end of a day’s work the physician would take his shotgun and look for something different from the usual chicken fare, such as a partridge or a guinea fowl. The other items were to be found in his old wooden chest which was a former medicine chest, where supplies such as potatoes sugar, salt, peanut cooking oil, kerosene for the stove and for the lamp and soap were stored : this was about nearly all which he could have with him. Health workers would deal with the people of the village for their meals.

Beside diagnosing lepers and patients with sleeping sickness or onchocerciasis, the physician also had to oversee that medications for the total eradication of yaws were supplied to everyone and that smallpox and yellow fever immunization plans at first, and also later the tetanus, diphteria and tuberculosis ones were properly carried out Beyond all these tasks he also had to prescribe the treatment of newly diagnosed patients.

Patients with Sleeping Sickness were referred to the sleeping sickness hospital where they could be treated.

Lepers remained in their village and every week, several years in a row, a nurse assistant riding his bicycle would come and give them their appropriate medication making sure they were taking it.

Despite all precautions the physician and his family had to pay their toll to local diseases they had been unable to avoid. The throes of malaria and of amoebiasis did not spare anyone. These tireless walkers had to contend with a condition named "craw craw". One of them wrote the following "Over the last two or three weeks I have had several open wounds on my legs above my ankles. They look like small ulcers, are prone to grow deeper and do not respond to any treatment (...). It is quite unpleasant".

A paper was published in the May11th 1911 issue of " La Clinique " magazine which gave an account of mortality in the ranks of the Colonial Army Medical Corps. From 01/01/1907 to 31/12/1910 (four years), 32 physicians and pharmacists among the five hundred of them who were on active duty passed away : all these deaths occurred while they were overseas, or when sailing back home or during their official absentee leave in France. They died of tropical diseases or of other medical conditions which led to an unusual fatal outcome in these exhausted organisms. As everyone can easily understand these are really terrible figures.

One also had to keep being in high spirit, to challenge demoralization and feeling down and to beware of irascibility and of the transient euphoria brought along by brandy with soda water or by indulging oneself in many other enticements.

But there were also many good reasons to have the feeling of being rewarded as the pace of health improvement was good and one year after another one could perceive the results : the decreasing mortality rate of infants and the subsiding of epidemics were good and unbiased indicators. Beside these numbers, the gratitude of those who had been able to avoid the usual fatal outcome of these conditions, was also comforting.

CONCLUSION

After shedding light on the results of the actions of these "bush doctors", one cannot help thinking that the only kind of action which applies in such situations is one that has to be carried on without any interruption by interchangeable personnel. In order to ensure efficiency, a public health policy has to be applied to a whole country over many decades in a row.

Goodwill is of course wonderful, but any improvement of public health is going to be short-lived and reversible if the undertaken efforts are discontinued or inconsistent. Colonial medical practice in the bush, is a good example of what had to be done at that point in time in Africa.