Critical Thinking in Healthcare: Reflections on Southern Sudan

Author(s): John Adieng Adwok FRCS (Edin), PhD

Associate Professor of Surgery, University of Nairobi and Consultant General and Endocrine Surgeon, Kenyatta National Hospital and Nairobi Hospital. [email protected])

A Vietnamese proverb states, “The mouse does not know life until it has been into the mouth of the cat”. The Vietnamese practice the Buddhist religion and firmly believe in incarnation or rebirth after death. The Southern Sudanese healthcare system has already been 'into the mouth of the cat' during the liberation war. Those of us who remember the dilapidated state of the healthcare services before and during the war do not want to see a similar system reborn or 'know life'.

We have to put our faith in the long process of conception, gestation, delivery, and nurturing of a modern healthcare system. Yet, faith alone or handouts from donors will not take us far and we must use our critical thinking skills to bring a new and effective healthcare system to life. Sustainable outcomes will not materialise without the use of creditable evidence based information. This is in sharp contrast to what is assumed, believed, or felt to be the right strategy.

What is critical thinking?

So what is 'critical thinking' and how does it apply to healthcare delivery?

  • Beistle, Smith & Nagel (1) describe critical thinking as simply putting structure to your thoughts or expanding your thinking in a thorough and systematic way so that it is possible to consider all aspects of a problem.
  • Hall (2. p39) eloquently summarised the status of skepticism or critical thinking thus: “Minds are not meant to change easily. Humanity has managed pretty well with instinct, magical thinking and superstition for a long time, and it will probably continue to muddle through. The scientific method is a recent innovation; it isn’t easy, and it doesn’t come naturally”.
  • Mole (3) defines critical thinking as “learning how to evaluate arguments and to sort truths from falsehoods”.

The key to critical thinking is to continuously and vigorously apply the methods of science to navigate the treacherous straits between “know nothing”, skepticism and “anything goes” credulity (4).

The healthcare professional has to be a critical thinker, ready to learn to evaluate arguments and sort truths from falsehoods in the context of evidence-based medicine as well as personal attitudes. Our world is full of people who believe in angels but not in germs in spite of ample evidence for the latter and none for the former. Hall (2) gives two examples of how knowledge obtained through reliable means is often ignored to guide healthcare practices.

  • At a presentation a chiropractor insisted that newborn babies need immediate chiropractic adjustment, because their necks are stretched to twice their length during childbirth, even by Caesarean section. A midwife who knew that was not true confronted him explaining that kind of stretch could not happen without killing the baby. To which the chiropractor assured the audience that, yes, the procedure does a lot of damage! 
  • Another presenter at the same meeting claimed that he did not believe in the germ theory arguing that if germs caused disease we would all be dead. He insisted that the only reason why people get sick is that their spines are out of alignment. 

Evidently, the chiropractors had no scientific evidence on which to base their claims. And it is surprising how many obviously intelligent but non-critically minded people would accept these assuming that the chiropractors had obtained their knowledge through reliable means.

Some alternative medicine practitioners, traditional healers, herbalists, and witchdoctors may harm patients, even causing death by delaying and denying evidence-based medical care to patients. Yet, many people often turn to these “healers” in the absence of a better alternative.

The time to act is now

Our dilapidated healthcare services in Southern Sudan are stretched to the limit and it will take a massive effort to introduce a 21st century healthcare model.

Possible obstacles to the emergence of viable healthcare services in Southern Sudan include:

  • Health policy lapses
  • Complacency
  • Dependency.

Healthcare workers and policy makers in resource poor countries have a tendency to regard existing healthcare systems as the norm or simply resign themselves to the prevailing conditions and wait for the World Bank or IMF to come to their ‘rescue’. Surprisingly, many of our policy makers believe that these Breton Wood organisations will solve all our problems. Most of the so-called aid (in fact loans that will be paid by future generations) rarely trickles down to those who need it most. The cost of a new Toyota land cruiser is sufficient to purchase mosquito nets that could save the lives of hundreds of children and pregnant women. We all know there is a massive healthcare vacuum that still requires to be filled in Southern Sudan 5 years after the Comprehensive Peace Agreement. Yet, these persistent healthcare issues will probably not be corrected by waiting for expensive handouts of questionable value.


Figure 1. “It might be an uphill task but it is time to act”(Adapted with permission from reference 5).

The suffering of the Southern Sudanese should jolt all of us out of the current complacency so we start working to fill the healthcare vacuum.  All the evidence is before us and it is time to act. It is not fair to heap the blame for our ailing healthcare system on the policy makers considering the fragile political climate we have had for the last 5 years. There is much that we could do as healthcare professionals to help alleviate the suffering of our people. It might be an uphill task, but it has to be done (see Figure 1). 

It is time for all healthcare workers to get involved and engage with healthcare policymakers in Southern Sudan to build an effective and efficient healthcare system. Using critical thinking methods in constructive arguments are not a challenge to authority as this is the foundation of modern scientific method. We have to critically examine what is assumed normal and proper practice whether in healthcare delivery at the individual or at the policymaking level.

The questions we should ask ourselves include: 

  • Is the current method wrong or ineffective?
  • Is there another and better way of doing it?
  • Can others confirm that this method works? 


As the Zen proverb states: “Where there is great doubt, there will be great awakening; small doubt, small awakening; no doubt, no awakening” (4 p20). Critical thinking is an integral part of evidence-based medical practice. It is a skill every healthcare worker needs so that healthcare delivery continually improves at all levels.


  1. Beistle, K. S., Smith, D. A., & Nagel, G. Critical thinking. RDH 2006; 26: 74-75.
  2. Hall, H. Teaching pigs to sing: An experiment in bringing critical thinking to the masses. The Skeptical Inquirer 2006; 30(3): 36-39.
  3. Mole, P. Skepticism in the classroom. Skeptic 2006; 12: 62-71.
  4. Anonymous. What is a skeptic? Skeptic 2006; 12: 5.
  5. Bartz, W. R. Teaching skepticism via the CRITIC acronym and the skeptical inquirer. The Skeptical Inquirer 2002; 26(5): 42-44.