Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Training of Medical Assitants in Mozambique
387
Only those students who pass the written, oral and practical examinations at the
end of the second year are admitted to the third year.
Twelve years ago Nordberg wrote in the British Medical Journal 2 that a victim of
a strangulated hernia in Africa had a 1 in 8 chance of receiving any surgical care, let
alone of a real surgeon’s performing surgery. Unfortunately the situation in general
has not improved since then, and there is evidence that it has in fact deteriorated
further. One obvious potential emergency resolution of the problem is the delegation
of major operations to health staff not formally trained as medical doctors.
The training of nonmedical personnel to perform certain health care tasks has
long been advocated. 3 Laboratory services (including blood cross-matching) and
the administration of general anaesthetics can be safely delegated to nonmedical
staff. It has been successfully demonstrated in parts of Africa and Assia 4-6 that trained
nurses and medical assistants can undertake surgical procedures. In June 1996 the
British Journal of Obstetrics and Gynaecology published a paper entitled “A comparative
study of caesarean deliveries by assistant medical officers and obstetricians in
Mozambique. 7 This study of more than 2,000 consecutive caesarean deliveries showed
that: (i) there were no differences in the indications for caesarean delivery between
the two groups; (ii) the surgical interventions associated with caesarean delivery did
not differ in the two groups; and (iii) the only significant difference was in the
incidence of superficial wound separation caused by haematoma, which was slightly
higher in the group operated on by the assistant medical officers.
The study concluded that training selected medical assistants to perform caesarean
delivery, even on patients in poor condition, is justified in settings where doctors
are scarce.
The major advantage of the option we have taken is that it saves lives. On the
other hand, we acknowledge that it is an option with increased risks for the patient
under treatment.
Although our experience shows that a technically safe laparotomy can be performed,
in settings without major surgical facilities. It is frequently more difficult.
That is why we insisted on close supervision of assistant medical officers before they
are allowed to work entirely on their own.
Yet the delegation of major surgery to nonmedical personnel remains a matter of
controversy. Traditional professional rules are challenged and limits of responsibility
altered. There may be reasonable grounds to doubt whether such delegation is compatible
with safety. There may be an excess of medical manpower available in some
over-serviced areas of the developed world in which squabbles may result in subspecialty
jealousies about who is qualified for or excluded from doing what. In
under-serviced developing areas, the preeminent concern is the overwhelming need
for health care services and the resource constraints that deny medical care to many,
in some instances most, of the population. Our responsibilities are first to see that
services are rendered to the desperately needy and then to upgrade the quality of
those services. In this continuing-crisis with increasing desperation brought on by
presures of a burgeoning African population living and dying in poverty, life-saving
expediency using all possible means is a more ethical medical response than professional
puritanism.
Although we acknowledge strong medical opposition to such developments, in
Mozambique we believe that in areas where there are no doctors and people are
dying by the thousands for want of care, it is surely better to provide second-class
health care service than none at all.
37