Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Outreach Dentistry
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official national government once my passport had been stamped. The “T. A.” (“Traditional
Authority”) carries the awesome responsibility of the citizens’ welfare in
many places I have worked, most recently in rural Malawi, and this has largely been
the default entity of the extended family in a tribe or language and cultural system,
rather than simply residents or transients in a given geographic or jurisdictional
area. Given such a patchwork, there is a variable service, often marked by two classes
of service: one is a public façade of basic health care to include oral health care, and
a second is one is which the citizens can opt above this level of care by purchase of
services in a private market for them. Cost-Sharing is one method of bringing the
services found in the latter back into the former, but as it was tried in Tanzania, it
reduced dental services, particularly preventive or restorative services, by over onethird
when the patient was required to co-pay. 7 In many areas of the world, such as
the aforementioned Malawi, the missions, churches or other charitable organizations
furnish more than half of the medical and dental care, (two-thirds of the quality
institutionalized care), largely supported by non-governmental outside expatriate
donor help. Even the vast majority of the central government’s own expenditures,
particularly for health care, are directly funded by outside donor aid in such nations
as Mozambique and other members of the HIPC group (Highly Indebted Poor
Countries.) Colonial systems of health care have failed 11 to keep up with the demand
for services, particularly in light of the two factors afflicting developing nations’
imbalance of need and resources—the unsustainable burgeoning population,
with unchecked fertility resulting in malnutrition and collapse of social structures
under the burden of this broad population pyramid’s base—and new disease entities
that carry an even more devastating acuity of illness, such as the African AIDS pandemic.
15 Even ex-patriates, capable of paying for oral health services, are frequently
unable to find such services in remote regions, sometimes portrayed humorously for
a first-worlder who knows that he or she can get out to where such services will be
available, 12 but not at all a light-hearted matter for those with no place else to go.
What, Then, Can We Do?
Against the somewhat gloomy view of the world’s rather deteriorating standards
of health and health care, with oral health conditions often being in the vanguard as
elective sources of postponable morbidity rather than urgent causes of mortality,
what can we do? We know little about the specific conditions the patients over there
might have and even less about the people who suffer from them. We have no idea
of the kinds of personnel, equipment, and facilities for care, nor even means of
getting ourselves and the equipment there and the authorization to do so. Fortunately,
you are not the first to feel motivation to help but uncertainty how to carry
out this response. Colleagues around you can express what they have learned in
carrying out short-term missions. 5 There are many resources that can facilitate your
expertise and instinct to be of assistance—twin capabilities in any motivated health
care helpers.
What you may encounter will be unlike almost anything you are used to from
your training or current practice in a developed world context. But, as reviewed
earlier, the principles of practice are universal, and anatomy, physiology inflammation
and healing are much the same on any side of any other artificial border we
might try to draw between one human and another, and health care is a nearly ideal
bridge over such barriers. 2 You may have to improvise, and exercise ingenuity 13 in
how to make the resources available into the kinds of support for the same prin-
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