Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Outreach Dentistry
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substitute for careful practice, well thought out. “If you do not know what to do, do
what you know how to do.” Professional practices are often more repetitive, defensive
and redundant in resource superfluous environments. Few parts of the world
can afford such luxury of redundant over-care, including our own, so that the purity
of practice based in principle rather than simply iterative applications of technology
is a refreshing new look to be learned abroad and carried back home. “Minimize
variation” may have been the industrial efficiency principle proposed for manufacturing
practices by Edward Deming, but that shows disregard for the fact that pathologic
processes may occur somewhat uniformly, but they do so in highly variable
people. “Ask not,” said Sir William Osler “What kind of disease this patient has, but
what kind of patient has this disease.”
Increasingly, our world is peopled with ever more diverse populations—not just
recognized in traveling abroad, but in the stream of the world’s mobile citizens who
find their way into our office doors closer to home. This intensive course in not just
tolerating, or accommodating, but reveling in, the diversity within the human family
that constitutes our patient population pays valuable dividends for the practicing
“home anthropologist” in each of us.
The “one size fits all” industrial widget model of “zero variation” medical and
dental practice may have consequences beyond the burnout seen in professional
disaffection. This may account for the paradox of medical and dental care at this
point after the turn of the millennium: never have we been able to do so much for such
few privileged people, who have never been less satisfied with the care they experience!
On particularly frustrating days in clinical practice I have occasionally burst out:
“The only difficult thing about the practice of surgery is getting to do it!” 1 The
layers of obstructionists between the professional and the patient, which have proliferated
in the name of regulatory control, cost containment, quality assurance, and
legal standards of care have removed the immediacy of professional satisfaction we
certified problem-solvers were proud to enjoy after separating a patient from a problem.
The new brokers that complicate, if not always enhance, patient care have
certainly dampened the enthusiasm with which some of us have recommended to
our successors our own branch of the healing arts. If any of these unsettling doubts
or professional restlessness may occur to you from time to time as you are pursuing
your domestic practice—or within the Academy itself at its half century point—I
have an antidote to recommend: welcome to the world of wonder in Outreach Dentistry!
Outreach
At the outset, may I remind you that “outreach” is not only the practice of traveling
to the far corners of the world and encountering very different people in an
exotic culture, and rare and unusual tropical problems with which you have limited
experience at home—all this may be true in some minority of instances, and we will
look into those for the features of fear or fascination they may hold for each of us. I
use the term “developing world” or “Third World” to describe the disadvantaged
circumstances in which people live within or outside geographic or political boundaries.
In parts of Africa, I can point to the highest standards of First World health
care that would be enviable in my environment on Pennsylvania Avenue; but, I
point out that there are parts of Anacostia, no further from me now as I write as are
the paradigm practices of some parts of the Washington DC community, that have
far more in common with the slums of Lagos than they do with the “world capital”