Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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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
37 388 Surgery and Healing in the Developing World This paper was presented at a symposium on surgery in the rural setting held during the insugural meeting of the Pan African Association of Surgeons, Elephant Hills Hotel, Zimbabwe, 31 August-5 September 1996. References 1. Vaz M, Bergstrom S. Mozambique—delegationof responsibility in the area of maternal care. Im J Gynaecol Obstet 1992; 38: (suppl):37-39. 2. Nordberg EM. Incidence and estimated need of caesarean section, inguinal hernia repair and operation for strangulated hernia in rural Africa. BMJ 1984; 289:92-93. 3. King M. Medical care in developing countries. Oxford: Oxford Medical Publications, 1987. 4. Chowdhury S, Chowdhury Z. Tubectomy by paraprofessional surgeons in rural Banghadesh. Lancet 1975; 2:567. 5. White SM, Thrope RG, Maine D. Emergency obstetric surgery performed by nurses in Zaire. Lancet 1987; 2:612. 6. Kanchanguith R. Postpartum acerillisation by nurse midwives in Thailands. Inst Fam Plann Perpect 1990; 16:55-58. 7. Pereira C, Bugalho A, Bergstrom S et al. A comparative study of caesarean deliveries by assistant medical officers and obstetricians in Mozambique. Br J Obstet Gynaecol 1996; 103:508-512.
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Surgery and Healing in the Developi
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Contents Foreword .................
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25. Dentistry .....................
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Editor Contributors Harold P. Adolp
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Foreword Surgery and Healing in the
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“poor, but modern”, as for exam
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There may be at least one considera
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It is that higher accountability th
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1 2 Surgery and Healing in the Deve
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CHAPTER 2 Surgery in Developing Cou
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2 10 Surgery and Healing in the Dev
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CHAPTER 4 International Surgical Ed
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CHAPTER 9 Lab-in-a-Suitcase: Saving
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10 72 Surgery and Healing in the De
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CHAPTER 12 Communication in the Thi
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CHAPTER 13 Anesthesia in the Third
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13 100 Surgery and Healing in the D
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CHAPTER 15 Basic Obstetrics and Obs
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CHAPTER 16 Pointers for American Su
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CHAPTER 20 Chronic Pyogenic Osteomy
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CHAPTER 23 Cleft Lip and Palate Sur
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CHAPTER 24 Outreach Dentistry: A Wo
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CHAPTER 1 CHAPTER 26 Reconstructive
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Reconstructive Surgery in the Tropi
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CHAPTER 1 CHAPTER 27 Factors Influe
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Distribution and Incidence of Tropi
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CHAPTER 1 CHAPTER 28 Population Dyn
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Population Dynamics Of Surgical Tro
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Metabolic Maladaptation 289 Introdu
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Metabolic Maladaptation 291 some of
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Metabolic Maladaptation 293 In this
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Metabolic Maladaptation Table 1. Si
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Metabolic Maladaptation Table 4. Go
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Metabolic Maladaptation 299 the rev
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Metabolic Maladaptation Table 5. As
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Metabolic Maladaptation Table 6. Co
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Metabolic Maladaptation 305 the ris
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Metabolic Maladaptation Table 8. Go
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Metabolic Maladaptation Table 10. G
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Metabolic Maladaptation Table 12. C
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Metabolic Maladaptation 313 cell an
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Metabolic Maladaptation 315 Biologi
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Metabolic Maladaptation 317 from io
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Metabolic Maladaptation 319 25. Lon
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CHAPTER 1 CHAPTER 30 Nutrition and
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Nutrition and Development in Africa
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CHAPTER 1 CHAPTER 31 Uterine Ruptur
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Uterine Ruptures in Rural Zaire Tab
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Uterine Ruptures in Rural Zaire 329
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CHAPTER 1 CHAPTER 32 Vesicovaginal
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Vesicovaginal Fistula in Democratic
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CHAPTER 1 CHAPTER 33 Ophthalmology
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Wanted 437 “outliers” in the he
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World Health 439 challenge: name fo
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CHAPTER 1 CHAPTER 44 Treating Other
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Treating Others: Human Sciences in
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Treating Others: Human Sciences in
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CHAPTER 1 CHAPTER 45 The Impact of
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The Impact of a Volunteer Medical M
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CHAPTER 1 CHAPTER 46 Field Notes on
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Field Notes on a Typical Day in a H
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Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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