Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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278 Surgery and Healing in the Developing World
of the late presentation of illness and the lack of hygiene and sanitation that may
contribute to communicable disease. It is fatuous to suggest that economic development
will resolve the differential in the morbidity of tropical populations (for which
a contrary witness is seen in many urban industrialized environments); but it is also
a Pollyanna cruelty to await economic development before proceeding with methods
of mitigating surgical tropical disease. There are methods of dealing with shortages
of skilled labor and materials that circumvent through ingenuity what may be
lacking in other resources, 5 and oftentimes these improvisations are the kinds of
surgical tricks that are a lesson that the First World visitors must learn from the
tropical healthcare workers: “How to handle larger volumes of sicker patients with
fewer resources” is a postgraduate course many of us need to study from those veterans
of longer experience in making do with what they have.
The first pitfall to be avoided here is the despondency that whatever can be
offered in face of such overwhelming need would be inadequate, so why even bother
to try? The single requirement for working in the developing world is a nearly infinite
threshold for frustration—with patients’ problems, with the limitations of staff,
with the inadequacy of resources by the standards of the First World redundancy
many of us had become quite comfortable with in other settings. In fact, almost any
contribution made in several small ways toward improvement gives very notable
and immediate rewards. As a surgical colleague would often say in such circumstances,
“You cannot fall off the floor,” and the encouragement to start is one of the
best contributions that can be offered from a colleague who has been there before.
A second pitfall (which one source 6 calls the “commonest pitfall in diagnosis”) is
the assumption that an immigrant must import his diseases with him. With only a
few notable exceptions, most Western diseases flourish in the tropics, but their presentation
may be modified by environmental and other factors. Common conditions
occur commonly, although they may have an uncommon appearance in an
unfamiliar setting.
Priorities are rearranged in the tropical setting, where a period of experience can
“reset” the pattern recognition that is such a consistent feature of physician behavior
as efficiency accumulates with experience. When the author first plunged into the
exhilarating experience of tropical medicine and surgery in the developing world
over three decades ago, 7 the carefully learned reflexive behavior had to be relearned
in the setting in which these patterns were now quite different. For example, right
lower quadrant pain in a young male has a rather circumscribed differential diagnosis
in the First World setting, whereas it would nearly invariably mean something
else in the Nigerian bush hospital setting where I found myself shortly after I had
learned the pattern revolved around appendicitis where I had been only shortly
before in a US University hospital. I made lists of the rare and exotic diseases I
would see and added them to my clinical collection. But, I shortly picked up another,
and possibly more valuable habit—I listed in my notepad the very common
conditions afflicting patients that filled over two-thirds of the inpatient beds and
three fourths of the outpatient office visits that I was not seeing in the tropical setting.
These conditions were not subtle and therefore easy to overlook, or not seen
because they required some special diagnostic testing that was absent, nor overwhelmed
by other problems that prevented them from ever developing, because of,
for example, foreshortened lifespan. These conditions were simply absent. In the
example of appendicitis, there was one patient who had once developed appendici-