Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Distribution and Incidence of Tropical Surgical Diseases
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hood malignancy correlated with latitude, altitude, rainfall and other patterns of
geographic propinquity. It is now possible to integrate this GIS (Geographic Information
System) into public health research into the control of tropical disease using
the GPS (Global Positioning System) and other readily available technology. 12 Burkitt
had extended his observations made in tropical environments in an attempt to explain
the relative scarcity of certain disease conditions in the tropics with the alarming
abundance of the same disorders in the developed world outside the tropics. 13
Patients May Be as Different as the Diseases, in the Tropics
Whatever the presumably known vector of some of the tropical diseases, there
may be some general conditions that affect the people living in the tropics, even
those who remain, for the time, healthy. The normal neutrophil count for the healthy
African living in Nairobi is 2,400/cm
27
3 14 or the albumin/globulin ratio may be reversed
compared to Western standards. Given the differences in nutrition and genetics,
it should not be interpreted as substandard to consider the majority of African
births to be of low birth weight or the growth curves in childhood not measure up to
a European norm.
To use the Sir William Osler aphorism: “Ask not what kind of disease does this
patient have, but what kind of patient is it that has this disease?” It may be well to
recognize the limitations of some of the surgical arts to fix some fundamental parts
of the patients’ problems. It may be that the patient has an enormous hernia of the
type in which the majority of the gut may be in the very grotesquely enlarged scrotum.
To repair such a hernia may seem like a technical tour de force, but it may also
mean that the patient cannot breathe after all that bowel, which had lost abdominal
domain, is pushed back up under the diaphragms and resulted in respiratory insufficiency—hardly
a favor in exchange for a hernia repair. There may be many such
examples in tropical patients in which we have a particularly good “hammer” in our
surgical tools for the directed repair of an immediate problem which may cause
further dislocations in the patient’s adaptations15 This is not a reason to forego the
immediate curative care for which surgery is remarkably effective, but to be culturally
sensitive as to the social context of this from of the healing art on which the
credibility of a good deal of primary and preventive practice rests.
The Coming Plague—of Development
In some of the “emerging economies” in the tropics, there is an economic stratification
of those, particularly in urban areas, who have adapted the First World’s
lifestyle and acquired some similar pattern of wealth in consumption. Such “economic
development” which is easily measured in the terms that generate numbers
economists use in such evaluations as that of the World Bank 16 may lead to the
accelerated onset of the First World plagues, largely absent in the tropics—hypertension,
coronary artery disease, degenerative diseases of the CNS, and metabolic
consequences of excess. 17 In one review of changing patterns of disease in the new
South Africa, an alarming accelerated epidemic of obesity and hypertension reflected
the dark side of this new urban economics, with the extremely constrained health
care resources already stretched thin that would have to be stretched beyond the
elasticity to cover the medical and surgical complications of this new wave of tropical
noveau-diseases. 18 Such a labor and materials and capital-intensive epidemic for
palliative care might even dwarf the staggering requirements anticipated for the burden
of HIV-associated disease in the tropics. 19