Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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440 Surgery and Healing in the Developing World
results measurable in blood chemistries and goiter size. What happened to the individuals
and the collective society of which these treated individuals were a part? An
increase in metabolic rate was accompanied by an increase in caloric demand —I
created hunger. Hypothyroidism is a low fertility state; a population explosion followed
the vertical health care program accompanied by a midwifery program which
together with the iodine repletion eliminated cretinism and decreased infant mortality
rates. A larger quantitative population of qualitatively enhanced consumers
resulted, with greater demands placed on the marginal rainforest environment and
ecologic collapse. I had done my job, within my professional best standards, and
why then is the world not necessarily a better place to live? Could it be that
single-factor intervention in a vertical health care program that is not sensitive to the
fragile biologic balance and not part of a culturesensitive development program
might result in medical maladaptation?
Let us return to the question “Why?” If the poorest 20% of the globe’s population,
located in a tropical and mountainous equatorial belt of resource-constrained
marginal lands, is where the 20% of the globe’s hypothyroid population lives—
-which is chicken, and which egg? Are these billion people poor because they are
hypothyroid, or hypothyroid because they are poor? And, if, you and I would agree,
hypothyroidism is a disease, and prevents people from realizing their full potential
as human beings (as exemplified in the extreme case of cretins whose development
never really gets started), why has it been conserved? Would not the population of
hypothyroid people have been eliminated in any competition for resources long
ago?
In some other instances of diseases that persist, such as hemoglobinopathies (sickle
cell anemia is an example), it appears that such diseases were conserved on areas of
the map only where other parasitic problems with a worse outcome were superimposed
on the same global map (malaria, in this case, to which the anemia conferred
a relative resistance). Could it be that the hypothyroid population may have a natural
adaptation to the world’s low resource environments through their low fertility
and decreased caloric requirements of this acquired disorder? And might medical
intervention through a single focus on the hypothyroidism in such populations,
without sensitivity to the cultural and ecologic context in which it was found might
cause more harm than good?
This example in a remote population may serve as a laboratory model of our
own environment. In a far more complex society, we are still dependent on the eager
and early applications of the triumphs of the medical model, “medicalizing” all social
problems addressed typically with some simplistically targeted treatment and
the gratuitous prologue “if they can put men on the moon, we can at least...” and
then we are puzzled and perplexed by persistence and proliferation of the medically
“conquered” conditions.
Humility in health care requires us to loiter long enough past our headliner
triumphs to be still observant and honest when the later consequences of our many
publicized victories are evaluated in the context of the humanitarian enhancement
of lives in individuals and the societies composed of them. To date, we in the First
World have absorbed far more medical resources, with greater ecologic impact and
with still less health satisfaction than the underserved populations we might little
understand, but still seek to advocate in “world health.”