Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Wanted
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most pathologic presentations are not subtle, having been long neglected and not at
all early in manifestation. Furthermore, the acuity of the physical diagnosis increases
with experience, relying upon eyes, fingers, ears, and (not infrequently) nose.
Many surgeons trained in exclusively First World environments express some
anxiety about encountering Third-World problems. They are reticents to encounter
what are often viewed as exotic diseases for which no training or experiences equip
them. However, knowledge of Western disease entities in atypical or advanced presentations
is more useful than a complete “retooling” for the tropics.
Even more remarkable than the exotic and unusual diseases that one encounters
in the Third World is the longer list of the degenerative diseases that fill four-fifths
of our First-World hospital beds that are absent in the Third World. Perhaps there is
some pattern in lifestyle or behavior that contributes to the absence of such diseases
that are so common in the western world, such as gastrointestinal cancer, atherosclerotic
complications (such as stroke, hypertension, and coronary artery disease), degenerative
central nervous system disorders, inflammatory bowel disease,
hemorrhoids, varicose veins, and peripheral vascular disease. 10
We may learn a vital lesson from practitioners in the Third World: They have
become experts in dealing with much more severe health problems in ever greater
populations of people with fewer resources, and this is a “postgraduate course” we
may need to master quickly as the resources invested in curative health care of degenerative
disorders stop expanding in the First World.
There are fascinating special disease condition in Third-World environments
that are not only interesting to study, but often yield to some ingenious management
methods. 11 there are but two season and dry season, present different disease
patterns and also complicate the care of open wounds. Water is often either absent
or present in excessive amounts. In addition to dangers from the endemic malaria
seasons, the postoperative patient may experience some blood loss and then postoperative
fever. Blood banks are rare to absent. Blood replacement is rarely available
except for immediate transfusion from family members, often in parabiotic circulation
after a quick cross match, with blood donors reluctantly parting with some
hemoglobin that may be only one or tow grams higher than that of the recipient.
When postoperative patients have had some blood loss, they typically have splenic
contraction and autotransfusion from this reservoir, and along with the blood infusion
comes a shower of plasmodia from tissue phase. So most postoperative fevers
are automatically treated with chloroquine in areas where drug resistance has not yet
made it less useful.
The families are very much involved in the care of the patient, constituting most
of the nursing, all of the dietary kitchen, and a good deal of the monitoring. It is the
family who gathers the firewood and the water from the stream that goes into the
pressure cooker autoclave for sterilizing the instruments, drapers, and laparotomy
pads for operation—all of which are reused, as are the gloves, needles, and every
other disposable product in the materials-intensive First World.
Endemic goiter and cretinism is an interesting metabolic response to iodine deficiency
in some geographic areas. Additionally, some dietary staples, such as cassava,
have the capacity to prevent utilization of the scarce iodine that is taken in,
exacerbating the problem of goiter. Repletion of iodine alone may not be the only
solution to this problem, but iodine administration does seem to have had a remarkable
effect in lowering the tragedy of complete development failure in cretinism. 12
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