Chapter 1. The background to surgery

Table of Contents
The unmet need for surgical care
The surgical scene
Twenty surgeons in one
Your surgical work
Your patients
Referral is mostly a myth
What should we describe? What should you be able to do surgically? The limits of this system of surgery
Should you operate?
''Oh, never, never let us doubt what nobody is sure about''
Creating and maintaining the surgical machine
The surgical care of the poor
Primary care radiology
How to use these manuals

You have just arrived at your hospital and have not yet unpacked, when the ambulance arrives with a note from sister to say that there is a patient with a strangulated hernia waiting for you. You have never done one, because the registrar when you did your internship wanted to do as much operating as he could himself. So you mostly assisted and were occasionally allowed to sew up the skin. All your seniors have left and have gone into private practice, so there is nobody to help you. If you refer this patient, he will die on the way.[][+3][f09] These manuals are dedicated to you. This personal reminiscence was contributed by Dr Michael Migue of AMREF, as describing the scene for which these manuals are needed.

The unmet need for surgical care

Surgically treatable diseases are not as important as the great killers of small children in the developing world[md]malnutrition, pneumonia, and diarrhoea. However, surveys from the rural areas of Bangladesh, from India and from urban South America indicate that 10% of all deaths, and almost 20% of deaths in young adults are the result of conditions that would be amenable to surgery in the industrial world. If even very simple surgical services were available two-thirds or more of these deaths would not have occurred. One study showed that for every person who died of an accident in the Punjab, there were eight who were permanently disabled.

A study in East Africa estimated that, per 100,,,,000 of the population; 225 mothers needed a Caesarean section, yet only 25 got one, 175 inguinal hernias needed repair each year, but that only 25 were repaired; 30 patients needed operations for strangulation, yet only 4 had them. Since a strangulated hernia is almost always fatal unless it is treated, this is a mortality of nearly 90%.

These are just two examples, one from India, and one from Africa, of the surgery that needs doing and is not done. All this unmet need means that there are many unnecessary deaths in remote villages from strangulated hernias and obstetric disasters, as well as from vesicovaginal fistulae and from cerebral injuries at birth. They illustrate the fact that district hospitals can only care for a fraction of the burden of surgical disease in the communities around them. The result is that millions of people, whom surgery might help, it does not help. Too many people still die from obstructed gut, or are disabled by untreated osteomyelitis, or burns contractures[md]much as they were in the industrial world a hundred years ago.

Once services are available to prevent the killing diseases of childhood, the simple surgical services described here should surely have the next priority. They can do much to improve the quality of life of the poor. Although much of this manual has a rural orientation, 44% of the people of the developing world are expected to be living in towns by the year 2000, so the surgical care of the urban poor will be almost equally important.

Surgery has an importance in the public mind that medicine does not have. It is also the most technically demanding of the tasks of a district hospital doctor, and is thus a good measure of the quality of his medical education. If this has not been adequate, either because it never was adequate in his medical school, or because the quality of its teaching has fallen, he will be very loath to do much surgery, and may do none. This is why some district hospitals, and many district hospitals in some entire countries, do little surgery. When this happens, patients soon realize that it is no use going to such hospitals, with the result that they soon have empty beds. So if you see a hospital with empty beds, one of the first questions to ask yourself is ''What is the quality of the surgery here?'' There is thus a qualitative aspect to the unmet need for surgical care as well as a quantitative one.

The constraints on the provision of surgical care are formidable. Here is one very special centre of excellence expressing them: (Nevertheless, over the previous year it had been able to increase its average daily number of patients by 14%, and its major operations by 7%.)

CONSTRAINTS HEROICALLY OVERCOME ''It is an anxious time. Costs are rising. The Ministry's manpower resources are scarce, making it well nigh impossible for them to take on the extra responsibility from the Church hospitals. The rural people are very anxious that the Churches continue their health work. It makes sense for both economic and humanitarian points of view. What of our Lord's call for compassion for the sick and identification with the poor? Where is the way forward?'' 1981 Annual Report St Francis' Hospital, Katete Zambia. Burk JF, Gill SG, King TC, McCord C, Rosenfield A, ''Report of a Panel on Emergency Surgery', IOM Committee on International Health 1977 National Academy of Sciences[-3] Nordberg EM, ''The incidence and estimated need for Caesarean section, inguinal hernia repair, and operation for strangulated hernia in rural Africa', British Medical Journal 1984;299:92[nd]3 Fig. 1-1 THE SCENE IN AFRICA. Ward 7 in Nyeri Provincial General Hospital. This is somewhat better than the average conditions for sub-Saharan Africa at the time of writing. Note the blood transfusion poster. You will see that there are several patients on traction, two with long leg casts, and that one of the beds contains two patients.