Book Review

Surgery for All: A view from the developing world

N Engl J Med 1995; 333:950-951October 5, 1995

Article

Surgery for All: A view from the developing world
Edited by Mushtaq Ahmed and seven others. 414 pp., illustrated. Lahore, Pakistan, Ferozsons, 1994. $25. ISBN: 969-0-10026-2

This small but weighty account of surgery began with the conviction that led its surgeon-editors, headed by Timothy S. Harrison, to venture into a land where their surgical skills were in short supply. Its message for surgeons rooted in the developed world is that there are huge populations with unmet needs for the simplest and most elementary surgical care. There are still people who die of strangulated hernia or ruptured tubal pregnancy, or who go through life crippled by congenital anomalies. There are still women condemned to pass a lifetime with rectovaginal or vesicovaginal fistulas because of the lack of modern obstetrical or gynecologic care. For those of us concerned about an oversupply of specialists, this book is a reminder of what life is like in places where there are not enough surgeon-generalists, indeed where there is almost no surgery at all.

In 1924 Harrison's father, Paul W. Harrison, a pioneer medical missionary in the Arabian peninsula, wrote The Arab at Home (New York: Thomas Y. Crowell), an account of an ancient civilization little known to the Western world. Now his son tells Western surgeons about the difficulties of providing modern care to primitive populations in the same region, which extends north to the Russian border, west to the Aegean, and east to include much of India and Pakistan.

Dr. Harrison, his coeditors, and their 25 collaborators include surgeons native to the Middle East as well as many from England, Canada, Australia, and the United States. All speak from personal experience. The book is profusely illustrated and includes many case histories. There are several chapters on endemic diseases with which most readers will have had little experience. The presence of trauma is constant throughout the book. The frontispiece is a shocking photograph of a man who has just had his face shot off. A few pages later, one sees him after surgical repair. It is clear that plastic, cosmetic, and reconstructive surgery is as essential to well-being as the familiar procedures of internal surgery.

It may come as a surprise to learn that renal transplantation and open-heart surgery are practiced in several centers in this area. It has long worried me that the introduction of new and complex surgical techniques to “underdeveloped” populations is inappropriate unless autopsies are widely available. How can a surgeon carry out a “new” operation with an unfamiliar team if there is no way of evaluating the causes of death? I would have welcomed more discussion of this scientific and ethical problem, although it is mentioned in passing.

Although autopsies are rare, even in Saudi Arabia the use of cadaver donors has become widespread, as is related by Abdallah Daar, who writes:

Today at least 50% of all transplants in Saudi Arabia are from cadavers. Singapore is making major efforts by encouraging its citizens to agree to donate organs after death. The shortage of cadaver organs in much of the developing world, particularly the Middle East, is not due to a shortage of suitable donors: these countries have extremely high road traffic accident rates.

Could it be that we are seeing a new phenomenon here — a willingness, because of social necessity, to use cadaver organs in countries where autopsies are rare?

To one who has witnessed the gradual assumption of responsibility by Lebanese surgeons for almost all the surgical specialties at the American University of Beirut, it is clear that a similar transfer of surgical care from the hands of visiting Westerners to those of highly trained native surgeons is occurring everywhere. Is this happening fast enough? How may we accelerate it? Bo Eklof and Sten Tibblin contribute a fine account of academic surgery in the developing world. Most readers would welcome more data on the numbers of university graduates who are becoming surgeons and on what numbers may be appropriate for the future.

Paul W. Brand (long a specialty surgeon in southern India) makes the following statement in his preface to the section on specialty care:

I observed the struggle for survival and saw the courage with which families work together for a good life. . . . We must not allow specialty surgery to be out of reach of local developing world economies. . . . The attempt to make technology available must never be regarded as a condescension or a step toward future higher technology. . . . We need to learn less extravagant ways ourselves. That experience will do us good.

To this, John H. Bryant adds:

And it [this book] speaks from the souls and hearts of surgeons who wouldn't be where they are, doing what they do, unless they had larger commitments to the needs of people and their countries than to surgery simply as a field of practice.

It is clear that any surgeon trained in the West who wishes to journey to the developing world to assist with surgical teaching and practice must undertake a major study before departing. This book would be a good place to start.

We are still a long way from “surgery for all.” For stay-at-homes, this book inspires an appreciation of the generosity and altruism of those who ventured forth to provide what other cultures failed to support — adequate care for their people. In the United States, under care managed for profit, will we soon need helpful visitors ourselves?

Francis D. Moore, M.D.
Harvard Medical School, Boston, MA 02115