Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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286 Surgery and Healing in the Developing World
operated in tropical environments before is the high number of obstetric disasters
and surgical requirements for operative deliveries or ectopic pregnancies. A surgeon
working in the tropics rarely has the luxury to refer or to decline participation in
such heroic feats outside the bounds of the usual surgical residency training programs
in the developed world as “accouchement force’”, seemingly endless series of
“pussy pelves” and the desperation of septic abortion or late labor fetal demise.
Adaptation, Given the Stresses of Environmental
Concommitant Conditions
A well known example of persistent disease patterns that continue to be conserved
despite apparent natural selection pressures that might have eliminated them
from being passed along are the genetic hemoglobinopathies. If we consider sickle
cell anemia, for example, this disease has a considerable mortality associated with it
particularly under some hypoxic stresses, and it would no doubt have been eliminated
from the human gene pool were it not for the heterozygous carrier condition
of sickle cell trait which can carry a relative immunity to red cell parasitism from the
malaria parasite. So, in areas of higher malaria endemicity, sickle cell trait would be
conserved. This is also true for some of the thalasemias adjacent to the Mediterranean
and other genetic illnesses which have been linked with pressure from other
environmental factors.
It is a worthwhile question to ask in our meta-analysis of medical and surgical
treatment of tropical disease, if we as therapists may also be factors in the natural
selection process, changing the nature of disease patterns not only from successful
treatment patterns that would, it is hoped, enable the postoperative patient a chance
to survive and mature to develop later degenerative diseases seen more commonly in
the developed world’s older populations. But, it may also be that we are operating in
an environment in which larger factors are also determinative of survival of those
who may receive treatment, and the disease patterns themselves. As an example
from one of the author’s experience, consider the case of endemic hypothyroidism
and cretinism in Central Africa. (Nutrition article, Dec 1999 and editorials referenced
here.)
If hypothyroidism is a disease (and almost all developed world physicians would
agree that it is since it subtracts so much human energy and individual development
potential) why has it been conserved? And, as it seems to have been conserved in a
distribution pattern that follows the tropics and high mountain or central rainforest
or desert areas of the world. These are areas also of endemic poverty in lands with
scarce resources. Which is chicken, and which is egg? Are the people poor because
they are hypothyroid or hypothyroid because they are poor? And is it coincidence
that the tropical areas of least energy resources is also the hypothyroidism endemia?
It may be that hypothyroidism is a metabolic disorder which may represent an
adaptation to areas of scarce resources (at least it is obvious that cretins could not
survive in a cold harsher climate in which a much higher metabolic level of activity
and energy utilization were required), and correcting the hypothyroidism in a patient
or a population that must remain in and contend with these marginal environments
may create metabolic maladaptation, if other steps are not taken to mitigate
the energy shortfall in macro calories after restoration of the micronutrient iodine,
for example (Nutrition articles).
Such thoughtful metanalysis of the demographic and epidemiologic transitions
that populations go through in the process of development had inspired Maurice