Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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322 Surgery and Healing in the Developing World
such conditions were rare to nonexistent only four to six generations ago in an
African setting. The harshness of the Middle Passage in the slaves/molasses/run triangle
may account for this as an “evolutionary knothole” through which this unnatural
selection occurred, if the tragic losses of this harsh traffic differentially favored
a “stingy gene.” Such a hypothetical gene or some combination that conferred metabolic
characteristics that gave survival advantage though the conservation of calories,
salt and water might be accountable for the new rash of metabolic disease in
changed circumstances of mineral, energy, and foodstuff abundance.
The authors’ evidence in their review of recent changes in urban African morbidity
might be used to postulate that the whole of the Sub-Saharan population of
Africa may have been strained through a similar nutritional knothole, through the
less geographically discrete and historically more protracted process of high infant
mortality and differential death rates from diseases when starvation is comorbid.
Rather than blaming a bad deal of the genetic deck, it seems there might even be an
innate protective effect, since obesity, hypertension, diabetes and stroke rates have
soared, but another “big ticket” first-world plague has lagged behind: coronary heart
disease, thankfully, has not kept pace, even as the other diseases bypassed the rates in
Europeans in similar environments. Their warning, however, is as dire as the predicament
is inevitable: although currently overshadowed and retarded by the infectious
plague of HIV/AIDS, that, uncontrolled, is holding back development in much
of the Third World, and is pulling some emerging economies back toward the more
primitive nutritional patterns, the impending rise of the coming plague of First
World-pattern cardiovascular disease will be an even more crushing burden.
It is refreshing to read an honest appraisal of conventional wisdom—which assumes
that we have, or are soon gathering, enough information to make major efforts
at prevention eradicate the big killer first-world diseases as effectively as we
have controlled, say, smallpox. As nebulous a risk factor as is called “life style” seems
to be correlated with a number of diseases, and is well worth working on to attempt
to reduce some risks. But the authors go on to state a politically unpleasant, if correct,
fact: we understand very little of the majority causes of coronary heart disease
and breast cancer and even such an apparently obviously preventable condition as
dental caries. All around our world, the environment is changing much faster than
any genetic drift could occur. Just at the time we have made an enormous investment
in the human genome project, we might come to the realization that, at least
with respect to nutritional balance, a lot more of our disease burden is Lamarckian
than Mendelian. We need to look up from our micro-analytic preoccupations and
take the long view, 2 and such meta-analytic reviews are helpful.
Other microenvironments have been examined as suggested laboratories of the
often unanticipated downside of development. 3 One example that shows the economic
dislocation of sudden passive wealth has lead to the world’s highest adult
onset diabetes, hypertension and renal failure rates within a generation of the phosphate
mining exploitation of the Pacific Island of Nauru, the UN’s smallest member
state, for now among its wealthiest per capita, and with a population being eroded
as much as the mining of the island’s base is by this recently acquired morbidity. 4
In a comparative study of populations within Mozambique over time, Maputo
province had relatively good records a century ago showing essentially no evidence
of hypertension and its consequences in this relatively urban province, in which
now the leading noninfectious cause of death in adults are these same hypertensive
consequences. 5 This might be a lesson to some of us attempting to replete certain