Surgery and Healing in the Developing World - Dartmouth-Hitchcock

4
20 Surgery and Healing in the Developing World
in both the diseases faced by the population and the levels of multiple service sophistication
sought in tertiary care hospitals. Surgical services must be provided
under a wide variety of technological settings, and “supplying the surgical needs of a
developing country” has a sociopolitical connotation, for there are many determinants
of available medical care. Eight years ago, an estimate was made that the developed
world invested from $30 to $150 per capita per annum in surgical services,
while the developing world invested between $1 to $5. In the interval, these figures
have increased severalfold for the developed world, but for the developing world the
data have remained unchanged and in some places have even diminished! As a means
of increasing health coverage, especially in rural areas, priority investment in primary
health care, including some fundamental surgical tasks, may be placed in the
hands of paramedical personnel.
The development of health care in industrialized nations may be viewed in three
stages. Challenges to public health and personal health services provided can be
classified in the first stage as that of infectious diseases, malnutrition, and poor housing.
The second stage is that of chronic diseases, such as cardiovascular and cerebrovascular
disease and cancer; and the third stage is that of social environmental
pathology—including accidents, alcoholism and other addictions, overnutrition,
and associated morbidity of each.
If socioeconomic development and well-being result in average life expectancies
that approach the maximum life span, acute illnesses have ceased to be a major
medical problem and have been replaced by chronic illness. This development implies
that the practical focus on health improvement must be on morbidity, not
mortality, for natural death will occur near the maximum life span. The problem to
be addressed is how to improve the quality of life through the compression of morbidity.
Eventually, the current limits to longevity are societal, not medical, problems.
Medical care systems in industrialized western societies are largely constrained
to improving the quality of life. Developing countries face a challenge of coping
simultaneously with all three stages, with just a fraction of the human and material
resources available to their industrialized counterparts.
The epidemiology of surgical disease is characterized by the same three stages.
But in developing countries there are unique complications that result from poverty,
illiteracy, malnutrition, tropical infectious disorders, and abysmal limitations of laboratory
and diagnostic equipment and hospital facilities. At least one component of
this situation is scarcity of scientific information in libraries or access to international
databases.
In addition, there are major differences in regional clinical pathology. For example,
in a temperate climate a low-grade increasing colonic obstruction in an adult
is most likely to be a carcinoma; this is not necessarily the case in a tropical climate,
where amoébic dysentery and schistosomiasis are prevalent. This difference is significant
because the carcinoma should be operated upon; with ameboma of the
colon, the condition does not require surgery unless an emergency arises since effective
treatment is available through nonoperative means. As a consequence, chronic
gut obstruction in one area of the world or another should be investigated for different
diseases with different treatments, and the mind-set fostered by clinical education
would be different in different areas. “Geographic surgery” would focus on the
circumstances and disorders unique to a given area that merit distinct emphasis.