Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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56 Surgery and Healing in the Developing World
a steady loss of ground in the struggle between mouths to feed and food supply. This
situation is being aggravated by the deaths of many very productive people in their
thirties and forties, resulting in the labour force being dependent upon the young or
the older people, both of whom are less capable of the output of the middle group.
Everywhere, money is the determining factor, and it was pointed out that what
might seem “nothing” in the developed world might constitute a fortune in the
Third World. Large sections of the population have little income so that direct taxation
is not possible. Indirect taxation by sales taxes etc. can only raise a certain
amount of money so that the national exchequer is inevitably shorter of finance
than in the more developed world. This reflects itself on the health budget which
exists in all countries in straightened circumstances. Thus money for salaries, supplies
of all sorts and development is inadequate.
This situation may be rendered more parlous by the fact that the overall poverty
of the people raises the temptation to take and enjoy something which is not properly
one’s own. The temptation to steal, particularly from someone as impersonal as
the government, may be overwhelming and security in the hospital system can be
very difficult, resulting in huge losses on all fronts.
Thus, in summary, in the Third World there are, by developed world standards,
deficiencies all down the line. This results in high infant and maternal mortality
rates, a high disease rate principally related to infection and trauma, a lower life
expectancy, later arrival of the patient at the health services than is for the best, and
only one slight advantage, fewer of the diseases of affluence.
Big adjustments have to be made by the physician arriving from the developed
world if a good contribution is going to be forthcoming. On the surgical side instrumentation
and anaesthesia may be adequate for routine surgical procedures, but
exotic ones requiring intensive postoperative care may not be possible nor even desirable.
Simple ways of doing procedures must be worked out using less complex
instruments, but possibly demanding a higher level of manual dexterity, while there
are some procedures which cannot be undertaken. It is useless to do a heart valve
prosthesis operation on a person from far away in the country who has no access to
anticoagulation and for whom a visit to the hospital may be a “one-off” event which
cannot for financial reasons be repeated. A similar situation exists in relation to a
shunt inserted for hydrocephalus where constant observation is required and indeed
in almost every field of medical endeavour—why start a patient on anti-retroviral
treatment if there is no money to continue the therapy? This may result in the
accusation, as this author has been accused, of practising one standard of medicine
for those in town, and another for those in the country. In a way that is so, but it is
not the doctor’s fault that the patient lives where he does and whatever treatment is
offered has to be tailored to the social context of that individual. It has also to be
understood that chronic illness is something which is beyond the ability of the extended
family to manage. At one time we used to fool ourselves with the belief that
“the extended family will look after him/her”. We discharged paraplegic patients to
their rural homes with that trite remark which excused us from doing anything else
for the patient. We soon found that the average paraplegic patient sent to the country
lives for less than one year and dies under appalling conditions—conditions
which are now being repeated daily as the rural population struggles to cope with
the onslaught of AIDS and the return of urban dwellers to their traditional areas to
die. If someone is to care for the patient they have to be taken away from some other