Surgery and Healing in the Developing World - Dartmouth-Hitchcock

International Surgical Education
These “exotic illnesses” usually require great sophistication on the part of the clinician
in an area in which they are not prevalent; however, the practitioner in the rural
setting at a small hospital that is devoid of technology is often better qualified to
interpret the meaning of an acute abdomen accompanied by icterus, fever, and upper
abdominal tenderness in terms of common disease prevalence.
There is an unfortunate trend toward the acceptance of lower standards for the
practice of medicine under the slogan of a more “nationalistic medical care” for the
less privileged nations of the world. Yet, we must face reality. Many nations cannot,
even remotely, hope to duplicate the technological sophistication of the educational
and service institutions of the industrialized nations. What solutions are possible to
stretch the limited resources over the larger demands? It appears clear that geographic
pathology has a socioeconomic connotation that cannot be overlooked. The
concepts of clinical epidemiology and population-based medicine must permeate
medical teaching, health planning, and service administration. Surgical training programs
in a developing country must include sufficient exposure to such aspects of
“general surgical care” as trauma, orthopedics, urologic problems, pediatric surgery,
and obstetrical/gynecological surgery. As a result, in those areas of the world where
conditions impose the requirement of an “overall general surgeon,” training programs
must be longer and not shorter than in the industrialized world.
A continuous flow of graduate students, faculty members, and research workers
must be maintained in those areas of the world where high standards and ample
facilities exist so that upon their return to the homeland these individuals can become
intellectual leaders and effective multipliers of advanced knowledge. And, most
important, the countries of the Third World must increase efforts toward the development
of local and regional centers of high scientific quality that can serve both as
nuclei for excellent training and as models of academic excellence. These countries
should do so, freeing themselves of false complexes of intellectual colonialism or
irremediable poverty, for they cannot accept a destiny of lower standards of medical
care for their deserving citizens.
Australia
Australia is a pluralist society that emerged as a nation from a penal colony where
Great Britain sent its excess prison population in 1788. With this unlikely background
it has evolved a rather unique culture and political way of life. In this land of
universal education, there has always been a desire to “bring back to size” those who
are successful or larger than life. This behavior in Australia is referred to as “Tall
Poppy Syndrome.” The tall Poppy must be “felled” to promote satisfaction of the
excessively average and almost guarantee mediocrity. Yet Australians have typically
sought a “fair go” for everyone, and part of each of these beliefs has gone into the
government’s leaning toward a salaried, regulated health service.
Before 1948, surgery was a marketplace phenomenon in which most graduates
went to the United Kingdom to train in surgery and other specialties. When the
Royal Australian College of Surgeons was founded, it represented the recognized
surgical certificate thereafter. Patients were private or in the public domain, and the
surgeons who treated the latter were known as “honoraries” and proud of it. In
1948, the labor government attempted to introduce a National Formulary, but this
first step toward promoting conformity was not accepted by practitioners. The failure
of this system produced considerable anger among labor politicians. When next
elected to power in 1972 after 23 years out of office, the labor government intro-
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