Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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390 Surgery and Healing in the Developing World
that they have learned they must first retrain themselves. Some eventually abandon
surgery altogether, but most eventually return to the country where they trained. It
should therefore come as no surprise to anyone that in most developing countries
there exists today a severe shortage of well-trained surgeons.
Some countries have belatedly recognized this problem and have established their
own surgical residency programs modeled after what is done in Europe or North
America. These models require an abundance of academic surgeons and surgical
specialists. Since developing nations have a shortage of both these resources, the
model has worked poorly and few qualified surgeons have been produced. What
works so well in wealthy nations has for the most part proven to be a costly and
embarrassing failure in the developing world.
The Importance of Vision
With few exceptions, the very same governments that are struggling to train
enough qualified surgeons for their populations are either actively discouraging private
and church-related hospitals from helping or are doing nothing to encourage
them to help, despite their proven ability to do so. The reasons for this have more to
do with national pride and satisfaction with the status quo by practicing surgeons
than with the quality of surgical education or the surgical needs of their populations.
In many developing countries, a significant portion of all surgical services are
provided by surgeons working in private or in church-related hospitals. In some
cases, these hospitals provide some of the best surgical care available. These hospitals
are usually staffed by either expatriate surgeons or indigenous surgeons trained in
North America or Europe who have retrained themselves in order to practice surgery
under more difficult circumstances. They are often experienced in surgical education
and are motivated to teach other doctors what they know.
Expatriate surgeons supported either by mission boards or outside agencies usually
are usually on fixed salaries and may find it advantageous to train others to
perform surgery because it lightens their workloads without reducing their income.
In contrast, surgeons employed by government hospitals may be so underpaid that
much of their income must come from their outside private surgical practices. The
shortage of qualified surgeons in their communities may allow them to demand and
receive exorbitant fees for their services. Since training others to perform surgery is
time-consuming and has the potential to produce competition and reduce income,
they may have little interest in training other doctors to become surgeons.
Until governments in these countries have the vision to pay academic surgeons
enough to free them from private practice and to reward them for training surgeons,
surgical education in government hospitals will remain a low priority, regardless of
what model of surgical education is followed.
In the final analysis, the greatest obstacle to providing more and better surgical
education in developing countries may not be a lack of qualified teachers or of
adequate surgical facilities, but of vision. If practicing surgeons confine themselves
to preserving the status quo because it benefits them or because they are unwilling
or unable to consider the needs of their poorer countrymen, the obstacles to training
enough qualified surgeons in developing countries will remain intractable. Unless
someone dreams about what could be done using resources that exist and that
are already on hand, surgeons who could do something to help will remain committed
to the status quo. This unwillingness to dream and to take risks for a better