Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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280 Surgery and Healing in the Developing World
or water-lack cycles. The dry and rainy seasons have special implications for tropical
surgery and the spoilage of some equipment and the kinds of environmental conditions
that will compromise patient hygiene. 9 The tropical days do not vary in length
as much as they do in the temperate zones, so that the tropics should not be thought
of as a European or North American summer day, but more like an Equatorial
equinox in these latitudes, with limited periods of daylight during which much of
the work must be accomplished in the scarcity of artificial illumination. This also
has implications for the surgical workload that is often limited by the daylight stored
as solar power.
The other geographic features that determine the micro-climatic conditions include
altitude, proximity to the sea, rivers, lakes or deserts, prevailing wind and
monsoons or harmattans, and volcanic or rainforest soils. Altitude has a major role
in the ambient temperature, a circumstance that has impressed itself on me as I have
stood on “Equatorial glaciers” on multiple points around the earth’s high mountains
well within the tropics, as, for example, at 00.00 on Kilimanjaro. It has seemed to
me to be confusing and perhaps an unfair or unkind trick, if not inexplicable, that
one can suffer both frostbite and the rigors of a malarial fever in the same setting.
Volcanic soils, the notoriously poor soils of rainforests with little organic nutrients
or soluble minerals within them, and mountain soils have been inadequate as
sources of both micronutrients and any sustainable yield of macronutrient calories.
These marginal lands have very limited carrying capacity, yet are pressed as home for
ever increasing density of populations. One result of these conditions is endemic
hypothyroidism and goiter around the globe’s equatorial belt10 in areas of iodine
deficiency disorders. Iron deficiency is compounded by the burden of helminthic
disease, such as hookworm11 which causes additional attrition in energy and its utilization
in learning and industriousness.
Floods may affect some parts of the tropical world when no rain has been experienced,
if they are within the pattern of some much larger movement of wind and
water—such as the flooding of the Sudh in the Sudan from the Nile’s output of
highland Ethiopia precipitation, or the Himalayan-generated monsoon seasons half
a world away. These global patterns are subject to periodic perturbation also, as has
been seen with the worldwide disruption following El Nino.
Endemic Disease of Surgical Consequence, Superimposable
on these Geographic Constraints
It has been well-known since the time of Manson that malaria is a mosquito-born
illness and that the patterns of much of tropical disease could be unlocked by a
knowledge of the entomology that underlay some diseases. This was not only true
for the plasmodia in their distribution with the seasonally cyclic Anopheles mosquito
breeding and feeding patterns, but second and third order diseases as well.
There were diseases directly related to the malaria—such as the nephritic syndrome
of blackwater fever—but also those genetic traits selected by the partial resistance
conferred by hemoglobinopathies that also produced blood dyscrasias such as sickle
cell disease and Mediterranean hemoglobinopathies.
One of the pioneers of the kind of epidemiology that led to clues as to the origins
of some kinds of tropical noncommunicable disease was Denis Burkitt, whose Great
Safari in a continuously-repaired station wagon brought back information of the
incidence, frequency, and pattern of an unusual maxillo-facial and visceral child-