Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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434 Surgery and Healing in the Developing World
lishes many cross-national reviews, research studies, and country profiles, and provides
a large amount of statistical information on all the countries of the world.
World Health Organization = http://www.who.ch/ —Home page to WHO,
with access to all its divisions and programs, and links to other relevant
Trauma is a common denominator across developed and developing worlds, but
in developing nations, there is no infrastructure of trauma care systems and teams.
Trauma surgeons in the First World are a familiar with the experience of operating
from the scalp to the soles, and with medical and surgical obligation to know and
treat all disordered vital organ systems in between. Primary care of the injured is a
prime surgical service. To an even more notable extent, a surgeon operating in the
developing world must rapidly become a universal surgeon, since he or she might be
called upon to treat and to operate in areas considered to be under the jurisdiction
of multiple specialties.
All surgeons need to know and frequently practice the surgical care of obstetric
disasters. Ruptured ectopic pregnancy is frequent in areas with a great deal of pelvic
inflammatory disease.
Upon my last trip to Swaziland I was asked if I wouldn’t mind seeing to a somewhat
urgent problem that might need attention before the elective surgical list that
I had drafted. I then walked into my first case, on this last visit to Swaziland, to find
myself doing a caesarian hysterectomy! I need not add that this was the first of these
procedures I had done, or even heard of, but I though it the right thing to do for an
eight-month pregnancy with a one-month dead fetus and a very dilated pus-filled
rupturing uterus. To quote a lesson learned from my Peter Bent Brigham surgical
chief, Dr. Francis D. Moore, “the sickest patients tolerate the biggest operations if,
but only if, they pay immediate metabolic dividends. “Subsequently, I was happy to
see the rapid turnaround experienced by this patient. Unnecessary operations are
not common in Third World settings; very necessary operations that go forever
undone are more likely the rule.
In a survey of health care in sub-Saharan Africa, appalling facts were uncovered:
if a patient has a strangulated hernia, the chances of seeing any kind of health care
personnel—surgeon, or doctor, or even trained health worker—in the village are
one in eight; and a woman who needs a caesarian section in sub-Saharan Africa has
a one in 20 chance of having it done. 9 The carnage that follows this unmet surgical
need is evident in the reeking outcasts with vesicovaginal fistulas or recto-vaginal
fistulas, some with perineal cloacas. For the repair of these obstetric sequelae, there
is a hospital devoted to this problem in the Sudan, with hundreds of patients waiting
for these surgical services at any given time. There are even more women who
have not been so fortunate as to experience this treatment, and they are buried in
graves all across the continent of Africa.
One of the more common emergencies among male patients is acute presentation
with an incarcerated hernia that has been long neglected. As already noted, very
few of these patients can obtain surgical services, even when they have an immediate
threat to life.
I once saw a patient who survived such an acute abdominal catastrophe. When I
first saw him, he had a spontaneous scrotal colostomy, the one outcome that might
be the rare exception to an otherwise lethal complication of ubiquitous hernias.
Advanced diagnostic laboratory and imaging studies are not usually available
where patients live —as electricity or a reliable source of clean water may not be
available either. Nonetheless, there is a diminished need for such facilities, since