Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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54 Surgery and Healing in the Developing World
distance may be as great as 50 km. Transport to these points of entry to the health
services or to the major centres may be lacking, though it is very much improved
compared to what it was, but lack of roads and only rough tracks deter the owners of
public transport from risking their vehicles in such circumstances. Health service
operated 4x4s may seem the answer but again they are just as susceptible to damage
on these tracks as are buses and other heavier vehicles. Then there is the problem of
summoning an ambulance when it is needed; communications throughout the world
are becoming better but where someone has to bicycle 25 km to reach a telephone to
summon the only ambulance, it can be realised that help for the distressed person
may arrive too late. Many a sick person or labouring young woman has been transported
long distances across country by wheelbarrow, bicycle, litter or on a strong
man’s back in a desperate attempt to reach help.
Inevitably there are problems in staffing such rural health centres. Highly trained
people who might be able to cope with a greater percentage of such emergencies do
not wish to live and work in such circumstances, and in any event it is not as though
an emergency situation of the sort just described arises every day. The problems of
adequately staffing these rural points and their connection with the centre remain
two of the major difficulties facing all Third World countries today.
By contrast the situation in the towns is somewhat better. Most large towns in
Africa have some form of water reticulation and sewage system so that aspect is
taken care of, but lack of housing with heavy overcrowding remains a very serious
problem. Throughout the world there is a steady migration from the country towards
the towns, where people feel that opportunities for employment are better,
the social life is more attractive, and even that the ordinary amenities of running
water and sewage disposal provide a step up from rural life. Medical services are
invariably better in the towns where there is usually a hospital with medical staff,
though they are always severely overcrowded. At least in the towns the health services
are to hand and can be reached with much less difficulty than in the rural areas.
Not only do medical services have to be provided and be available, but people
have to use them. It is well known that the greatest use of the health services in the
developed world is not made by the poorest section of the population, but by the
wealthier and better educated groups. Poor people have more important things to
think of than a minor ailment which does not incapacitate them. In two surveys of
health problems in the rural areas conducted 27 and 17 years ago in Zimbabwe, it
was found that over 40% of persons casually examined had some sort of problem,
albeit mild in most cases, that would have taken most persons of the First World to
seek medical assistance. In the developing world there is therefore an enormous
volume of work to be done both on the therapeutic and the preventive sides, but
there are enormous restraints imposed by many factors. In these surveys those interviewed
were specifically asked why they did not go for treatment, most said, “it does
not bother me”, others said they did not have the money for the bus fare or to pay
for the treatment. The demand for health care is therefore less than might be imagined
and indeed it came as a great surprise that so many people harboured some
form of disorder without seeking treatment. Subsequent studies showed that ten
times as much surgery was being done on the wealthier and better educated sections
of the population compared to the equivalent number of the poorer people despite
the apparent availability of the service. When this was first noted 25 years ago, we
were very surprised; not so now that the reasons for the differences in demand are
realised. However this is not the only problem in that regard.
Western type medicine has only been practised in Africa for about 100 years,
whereas before that, for centuries, there had been and still are the “traditional heal-