Surgery and Healing in the Developing World - Dartmouth-Hitchcock

World Health
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challenge: name for me a single disease for which improvements in diagnosis or
treatment have reduced the incidence of the disorder.
A response, thought to be primitive, early on in the medical anthropology of
struggle with disease invasion is “Why?” Why me? Who has sinned, that this visitation
should have fallen upon us? Who has inflicted this evil upon us? With enough
resources invested in the micro-analysis of the process, a taxonomy evolves to answer
the questions of “How?” “What have we done wrong?” kinds of questions are
typically replaced with “How might this disorder be prevented?” as further information
is accrued and manipulated. This “information science” has led to control of
some diseases, but eradication of few, and before we might take the next step toward
mastery of health, the more mature question “why?” reemerges. One of the most
renowned founding fathers of reductionist anatomic pathology, Rudolph Virchow,
had this surprising insight: “Whenever mass disease occurs, it is a result of ‘disturbance
of human culture.’”
To enter this meta-analysis into causation of disease may seem to some to be
outside the limits of the license to practice issued to Virchow the pathologist, Geelhoed
the surgeon, or you the reader, among all of us sharing the morbidity and mortality
that makes us human...and potential consumers of medicine’s resources. But it may
give us some insight to address the paradox of modern medicine at the millennium:
never have we been able to do so much for such complex and serious diseases so
effectively, using such sophisticated and costly technology and manpower resources
to manipulate this information, for a privileged population in this country which
has never been less satisfied with health services. And these inadequate, even if redundant,
services apply only to the over-cared-for first-world population, which
lives contemporaneously with many more global citizens who cannot enjoy even so
much as a fraction of a percentage of the care that is wasted on the other side of the
north/south border. As the stentorian tone of the disembodied voice warns us as we
approach the station in the London tube: “Mind the Gap!”
How can we advocate “world health” for a global population when there are such
gaps in socioeconomic and cultural milieu in which the same medicine is to be
practiced?
I may use an example from my own experience relating to the large part of the
global population which is hypothyroid, for reasons of iodine deficiency or its impaired
utilization, and which, presumably, might be readily treated by replacing the
simple, ubiquitous, cheap micronutrient iodine. “This much we know, and this we
can do, so let us achieve universal coverage in this vertical health care program, with
a target date of the millennium” declared the World Health Assembly of 1990. This
is a classic medical model of “one ill, one pill, one bill” with simplicity as its largest
appeal. Just how difficult can that be? The target date was not achieved, and the
problem, far from eradicated, may have grown larger in the interval—as quite typically
occurs in vertical health care programs that appeal for programmatic funds.
I conducted such a program of iodine repletion in a profoundly iodine deficient
population in Central Africa, and stayed on—some might say, too long— to observe
the results. The iodine repletion works: cretinism was eliminated and giant
goiters shrank, and those that were troublesome for airway management were operated
for demonstrable relief. This could be a model of success in vertical health care
programs, achieving real and measurable results nearly immediately.
But I stayed on to ask the further consequences of success or failure in the more
difficult terms of humanitarian benefit, beyond the morphologic and functional
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