Surgery and Healing in the Developing World - Dartmouth-Hitchcock

42
436 Surgery and Healing in the Developing World
There are skilled practitioners in parts of the Third World who continue to operate,
often heroically, against the daunting demand and with meager resources.
Not all of them have been to medical school, or even to any kind of professional
school. Surgeons with formal training in all aspects of surgical care are rare in Third
World environments, and where they do exist is typically the urban centers. There
are few surgeons, aside from dedicated missionaries, in places such as rural Africa.
When I had visited and worked with Charles Woodrow, MD, FACS, in Maurrere,
Northern Mozambique, my presence doubled the number of Fellows of the American
College of Surgeons in Mozambique, a nation of 28 million people that counts
a total of four Mozambican surgeons. There is one Malawian surgeon, in a nation of
18 million souls.
In Tanzania, for example, there were less than 100 specialist physicians, and all
of them, with a few exceptions, were in the capital of Dar es Salaam. Apart from
missionary physicians, there were no Tanzanian surgeons outside the capital.
Urban Africa may be growing rapidly, for better or worse, but most of the
third-World population is resident in the rural areas where they eke out subsistence
in hunting, gathering, or stoop-labor agriculture. 13 As the standard of living rises in
a small segment of the urban population, disease patterns, health care, and social
behavior change as the gap between urban and rural widens. Even as some improvement
has been noted in third-World productivity (as measured by an increase in
gross domestic product), this marginal increment has been overwhelmed by the
much greater increase in population growth, and the standard of living has continued
to fall. The distance today between First -and third-World standards of living
and that of our own colonial times, and it is apparent in each of my succeeding
visits, over now more than three decades, to the Third World that this gap widens. 14
The First World has been producing superb surgeons with highly developed
skills that have generally been exclusively dedicated to the care of only 6 percent of
the world’s population. Fully 90 percent of the world’s surgical needs are outside of
the U.S. and Europe.
Many of the American surgeons in practice today have noted a shift in their
practice pattern and satisfaction in surgical service—they seem busier than ever with
required paperwork, but less patient care, with some surgeons operating less than
one full day per week. Redundancy in surgical services may be expensive, and a
large, fixed, and idle capacity may be a waste of a precious resource in worldwide
scarcity of supply.
There exists a great, even overwhelming, need for our surgical services. Their
statement is less true than ever before with respect to the practices in our home
environment, and more true than ever before with respect to an expanding and
needy world. Students sitting in medical school classrooms today are not likely to
find their immediate neighborhood pleading for their specialty services. If they have
an interest in surgery, it will not be because of an overwhelming need and demand
for those services in almost any urban or even rural part of North America or Europe,
or the major capitals of South America or Asia. Surgical services are needed
where people live, and increasingly these are the regions of the world in which surgeons
are absent.
We have enjoyed the rapid advance and maturation of surgical technology in
much of the First World; but can this truly be called the golden age of surgery, when
whole nations have no qualified surgical services? World-class surgeons who have
dedicated omnibus per artem and find themselves redundant, or the superfluous