Surgery and Healing in the Developing World - Dartmouth-Hitchcock

27
282 Surgery and Healing in the Developing World
What Can—and Should—Be Done to Try to Balance the
Surgical Skill Supply and Larger Needs in Tropical Surgical
Care?
There are no shortages of challenges in tropical medicine 20,21 and these problems
of daunting size and scaling up at an increasingly rapid rate are particularly true of
tropical surgery. In a nation such as Malawi, 22 the population and its surgical needs
have recently doubled, and little else in that nation has, with a physician:population
ratio of less than 1:80,000, one of the least well-supplied in the world. That is considering
that less than 35 of the 84 physicians are Malawian and the majority are
expatriate physicians serving as missionary doctors. Few of these are trained surgeons,
yet all must confront surgical problems, never less than 15-25% of the patients
attending one of the two dozen hospitals. The credibility of a great deal of the
primary and preventive care effort rests in the capacity and care for the acute surgical
curative need—such as the ever-present obstetric disasters, the worldwide plague of
trauma, attending both transportation and inflicted violence.
A realistic view of the political and economic overload resting on surgical care is
described by an indigenous Indian surgeon in a specialty hospital in the nation’s
capital 23 and it may not be pretty with the day-to-day frustrations of someone trained
in First World settings to adapt to the high demand and short supply of a developing
world facility, but the reward in attempting to serve under such conditions is
also quite clear. One suggestion is for the First World in the temperate zones to
develop “world-class surgeons” 24 in collegial collaboration with those working in tropical
surgery in order that they may exchange specific expertise and learn from each
other in the various adaptations each must carry out in practice in very different
settings and resource environments.
Another suggestion is for a chair of tropical surgery 25 as a legitimate specialty
interest for consideration. But, with the rapid expansion of the need and demand
for surgical services in this major section of the world’s people, it may be that a new
cadre of surgical primary care ancillary personnel will need to be specially trained to
do a limited number of the emergency procedures where there are too few surgeons
or rapid transfer systems to get such patients to a center for specialized care. Such a
“Tecnicos Cirugicos” system has been well implemented in Mozambique 26 and has
been supported by Royal College of Surgeons leaders. 27 The tropical surgical world
is not pausing for new initiatives before exponentially expanding its tropical surgical
needs.
A Two-Way Educational Process in Collegial Collaboration
Tropical surgery is a fascinating and challenging personal and professional commitment.
It is involved, to be sure, with the exotic—illnesses secondary to schistosomiasis,
a trematode, or onchocerciasis, a filarial worm, or atypical sarcomas or
lymphomas despite a relative paucity of emerging epithelial carcinomas. It shares
with the temperate zones the same numbers of congenital malformations, and an
intensifying plague of trauma, but has unique infectious surgical problems, with an
underlying poverty of resources that complicates both the disease and its care, and
requires resourcefulness to improvise and adapt for successful solutions. This is a
very fruitful area of clinical investigation and skilled improvisation in new techniques
for more efficient delivery. Many of our tropical surgery colleagues have been
there far ahead of us and we have much to learn to catch up to address a problem