Cotton, Michael

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EDITORIAL PERSPECTIVEThe Academic Discipline of Tropical SurgeryMichael H. CottonPublished online: 7 July 2010 Socie´te´ Internationale de Chirurgie 2010Over 2 billion people, more than a third of the world’spopulation, live in the tropics and sub-tropics. In most ofthe countries of these regions, the risks of injury or deathfrom trauma is hugely greater than in the affluent West.Furthermore, obtaining surgery for eminently curableconditions is difficult, expensive, and often hazardous. Anestimate has been given that approximately 11% of theglobal burden of disease is surgically treatable [1].Simple procedures that could transform a young per-son’s life (for example, club foot manipulation or evensimple childhood inguinal herniotomy) have the potential,at minimal cost, of transforming a life. To change a youngperson’s crippled existence to full participation in societyhas the cost–benefit potential of decades rather than yearsor months.Such analysis appears self-evident for many healthcareworkers with first-hand experience in resource-poor coun-tries. Twenty years as a general surgeon in Zimbabwemade this abundantly clear to me. Policy makers, however,do need statistics, and it is a welcome sign that more andmore data are emerging to demonstrate that surgery isindeed cost-effective.The World Health Organization (WHO) has recognizedthe need to roll out surgery for the masses in the developingworld [2], noting en passant the dire consequences oftrauma, which has reached almost epidemic proportions inmany places. Trauma remains largely maltreated oruntreated. Its effective treatment is, by definition, surgical.Until recently, surgery was considered an expensive luxuryfor enthusiasts, but major improvements in care have beenshown to be achievable without huge cost inputs [3].Real medical impact in the tropics was initially soughtby dealing with global problems of gastroenteritis, malaria,malnutrition, and, more recently, human immunodeficiencyvirus (HIV). Immunization programs removed poliomy-elitis from the world scene; spraying limited the advance ofmalaria, and many exotic tropical diseases once endemichave been virtually eliminated. The World Health Orga-nization introduced its highly effective essential drugsprogram and the World Bank launched its essential clinicalpackage. A Caesarean section is the only surgical inter-vention within this package, and it remains the commonestnecessary surgical procedure worldwide. Nonetheless it isbecoming manifestly apparent that a basic list of surgicalprocedures could be drawn up that would cater to the needsof 90% of cases. The skills of a senior specialized surgeonhave been shown in one study to be unnecessary in 86.4%of cases [4].However, the attitude toward surgery is changing. Wemay call this surgery for the under-resourced 2 billion ofthe world ‘‘Tropical Surgery,’’ for want of a better term.But who will direct this new focus on Tropical Surgery?Who will direct its path? Where will the surgeons for theWHO recommendations, for example, for circumcision todiminish the incidence of HIV disease, be found andtrained?Training programs in many countries are wedded to old-fashioned Western models that are now inadequate to dealwith the exigencies of the demand. The pursuit of spe-cialization leads to well-qualified experts willing only topractice in specifically equipped centers of excellence,usually in private practice. Their contribution to the globalsurgical need is minimal, and yet they cost their countriesvast sums in terms of educational input. Initiatives, such asM. H. Cotton (&)Service de Chirurgie Visce´rale, Centre Hospitalier UniversitaireVaudois, 1011 Lausanne, Switzerlande-mail: mikeytha@gmail.com123World J Surg (2010) 34:2269–2271DOI 10.1007/s00268-010-0701-3surgical camps, specialist outreach, and decentralization ofsurgical services, aim to push surgeons out of cities into therural districts [5], but these represent top-down rather thanbottom-up strategies. In reality, the result is an obscene mixof high-technology surgery for the rich and practicallynone for the poor, even within the mega-metropolises ofthe world.It is a sine qua non that the long-term solution to alle-viating the global burden of surgical disease lies in buildingup a domestic surgical workforce capable of responding tothe major causes of surgically related morbidity and mor-tality [6]. However well-meaning or well-funded, thearmies of volunteers or short-term expatriates will onlyprovide a stop-gap, and they may cause more problemsthan they allieviate [7]. They remain hopelessly discon-nected and individualistic.Training for basic surgery needs to include non-physi-cians [8], must include basic anesthesiology, and has toconcentrate on the essentials of surgical practice. Thesefundamentals must be co-ordinated with the perceivedneeds in order to equip a series of frontline doctors able tostand in the breach. Such training needs to be streamlinedand speeded up [9], and this is the primary urgent task of anacademic discipline of Tropical Surgery.Academic institutes of tropical medicine, which havebeen established for many years in different parts of theglobe, have made excellent contributions and have had anunmeasurable influence worldwide. However, despite theireffectiveness, the personnel of such institutes generally donot have the resources, time, or expertise to devote them-selves to topics related to surgery.Moreover, academic centers in the tropics are them-selves struggling against the odds, and have, like theirclinical counterparts, been left behind in the advancingtechnological and electronic age. Thus a disparate group ofsurgeons, frequently struggling with a lack of resources,certainly without sophisticated secretarial assistance, andalways without much funding, is left to contribute to theworld’s understanding of surgery in the greater part of theglobe. They have formed individual groups, and much likethe volunteers and expatriates, and often in combinationwith them, do their bit in an uncoordinated fashion.What does this type of surgery involve? What does itcost ? Is it, in reality, any different from surgery in theWest? Is it merely surgery practiced in a more exoticenvironment, with perhaps some esoteric conditions, andmaybe in unusual surroundings? Surely a hernia remains ahernia whether in Birmingham or in Birmitrapur.The ramifications of surgical practice in the tropics are,indeed, various and varied, as has been shown by Wellinget al. in their description of the sins of humanitarianmedicine [10]. Facilities are often basic, technological helpscarce, financial means limited, and time at a premium.Surgeons may have to operate with minimally trainedassistants, they may have to perform procedures withwhich they are not fully conversant, and they may have toperform some basic anesthesia without a trained anesthe-siologist; they will always have to improvise [11].Does this mean that such surgical practice is a priorisubstandard? Surely not, if proper instruction can be madeavailable and a methodology can be introduced that takescognizance of the situation as it exists in practice on theground. Surgery must be done with what is to hand, and notto be deemed impossible just because some advancedgadgetry is not available [12]. Great improvements intrauma can be achieved with minimal financial and tech-nological input.The results will be the measure by which standards canbe set. But where are the data on results? Unfortunately,most surgery that is done is not submitted to any kind ofanalysis [13]. This means, of course, that there is practi-cally no information about the suitability and efficacy ofmuch surgery that is done in the tropics. However, muchamazing and brilliant work is done in adverse circum-stances. The lessons learned are, however, by and large,never disseminated to a global audience. Furthermore,when a new technique appears, for example the Lichten-stein mesh hernia repair, there are no data to support itsapplicability compared with other methods. Nonetheless, itis frequently religiously recommended as a new goldstandard for the tropics because it has been deemed so inthe West. Is this good practice? Is it good logic? Is this asort of medical imperialism? Is it indeed realistic?An enormous amount of surgical data awaits analysis inthe tropics: the amount of pathology is so huge, and sodiverse, that theses galore are waiting to be written with thematerial available. But, at present, this vast resource is notbeing utilized [14]. Little surgical research emerges fromthe tropics, and what is written is often side-lined, orconsidered of esoteric relevance only. For example, muchinformation about surgical tuberculosis or HIV publishedin learned peer-reviewed Western journals is based onanalysis of small numbers of patients and is therefore ofdubious significance. Yet there exists in the tropics atreasure trove at least as fantastic and rich as the contentsof Tutankhamen’s tomb.Of course, Tropical Surgery can also and must includethe treatment of specifically tropical diseases, such asschistosomiasis, ascariasis, Chagas’ disease, and leish-maniasis, among others; but the subject desperately needsto encompass how to cope with surgical patients in theirown environment. The impact on surgery of widespreadtropical conditions, such as sickle cell disease, or anemiasof various kinds, quite apart from general malnutrition orthe whole panoply of HIV disease, has also to be analyzedand understood.2270 World J Surg (2010) 34:2269–2271123In fact, surgery among a cohort of patients with HIVdisease is a vastly underexamined subject. Clinical researchhas concentrated on the HIV-related conditions that maypresent to the surgeon, the risks of clinical exposure, and ofcourse the effects of anti-retroviral therapy. However,experience of those in the field shows that non-HIV-relatedconditions appearing in untreated HIV-affected individu-als, such as appendicitis or peritonitis for example, presentoften quite bizarrely, and many of the traditional parame-ters of diagnosis are simply not present. Though these factsmay be known to many who have gained considerableexperience working in areas where HIV disease is rife,their expertise is not widely disseminated.Through basic grounding in essential surgery, the tropicalsurgeon inevitably becomes a jack of many trades. This neednot mean that tropical surgeons are masters of none; indeed,their very generality enables them treat their patients aswhole persons, and as a result they can adopt a holisticapproach to practice much more easily than their Westerncounterparts [15, 16]. Anyway, Tropical Surgery inevitablyencompasses a very general field, including gynecology andobstetrics. In these fields, par excellence, the place of pro-cedures almost forgotten in the West, such as symphysiot-omy, uterine surgery using a cervical tourniquet, orvesciovaginal fistula repair, may be properly evaluated.Is then global surgery just for the enthusiast or the WHO?Quite apart from the moral imperative, there is a hugeamount of knowledge and experience to be gained by cross-pollination of ideas and practice. The West must rid itself ofthe paternalistic notion that it knows best, and in humilitylearn from those who may actually know more but have less.All too frequently surgical teams are dispatched to far-flung parts of the world to deal with consequences ofdisasters, natural or man-made; these teams obviously needto be briefed about conditions on the ground, and themedical environment in which they will find themselves,quite apart from the sociopolitical background that exists.Even with all their modern equipment transported to thescene, emergency teams will always have to improvise, andfor this they need the experience of the tropical surgeon.They will often, just like the surgeon working up-countryon his own, have little access to immediate laboratoryback-up, and so will need to know how to evaluate fluidand blood deficits accurately by clinical estimation alone.For this, they will need clinical instruction from those whohave had to work in such situations. They also need to beprepared to work ‘‘outside their own box.’’ Indeed, as anorthopedic surgeon found when flown out from the West todeal with tsunami victims in Indonesia in 2005, his first(and most important) necessary surgical intervention was aCaesarean section! (Mannion, personal communication,2005), something for which he needed an instructionmanual [17].Training and research will go hand-in-hand with part-nerships. Many centers are keen to get involved and wantto know how. Whereas a nonpolitical center such asSwitzerland may seem ideal, with close contacts withWHO in Geneva, in practice many places could use theirown resources to great benefit, whether public, interna-tional or private, together with funding from philanthropicagencies such as the Gates Foundation.The establishment of Academic Centres of TropicalSurgery, mooted 20 years ago [18], has come of age. It is anurgent priority not just for the 2 billion people in the tropicsand sub-tropics, but for the future of surgery in the West.References1. Ozgediz G, Dunbar P, Mock C et al (2009) Bridging the gapbetween public health and surgery: access to surgical care in low-and middle-income countries. Bull Am Coll Surg 94:14–202. WHO Global Initiative for Emergency and Essential Surgical Care.www.who.int/surgery/mission/GIEESC2005_Report. Accessed 1July 20103. WHO Safe Surgery Saves Lives. www.who.int/patientsafety/safesurgery/en. Accessed 1 July 20104. Watters AK, Bayley AC (1987) Training doctors and surgeons tomeet the surgical needs of Africa. Br Med J 295:761–7635. Ozgediz G, Galukande M, Mabweijano J et al (2008) The neglectof the global surgical workforce: experience and evidence fromUganda. World J Surg 32:1208–12156. Chu K, Rosseel P, Trelles M et al (2010) Surgeons withoutborders: a brief history of surgery at Me´decins Sans Frontie`res.World J Surg 34:411–4147. Nthumba PM (2010) ‘‘Blitz surgery’’: redefining surgical needs,training, and practice in sub-Saharan Africa. World J Surg 34:433–4378. Sani R, Nameoua B, Yahaya A et al (2009) The impact oflaunching surgery at the district level in Niger. World J Surg33:2063–20689. Monjok E (2009) The neglect of the global surgical workforce:experience and evidence from Uganda (Letter). World J Surg33:150–15110. Welling D, Ryan JM, Burris DG et al (2010) Seven sins ofhumanitarian medicine. World J Surg 34:466–47011. Meier D (2010) Opportunities and improvisations: a pediatricsurgeon’s suggestions for successful short-term surgical volunteerwork in resource-poor areas. World J Surg 34:941–94612. Meo G, Andreone D, De Bonis U et al (2007) Rural surgery insouthern Sudan. World J Surg 30:495–50413. Nordberg E, Mwobobia I, Muniu E (2002) Major and minorsurgery output at district level in Kenya: review and issues inneed of further research. Afr J Health Sci 9:17–2514. Research out of Africa (2010) Lancet 375(9725):149615. Kasotakis G (2009) Requiem for the general surgeon. Bull AmColl Surg 94:20–2216. Hedges J, Ruscher KA, Chu K (2010) Is the generalist surgeonobsolete? Bull Am Coll Surg 95:24–2617. King M, Bewes P, Cairns J et al (eds) (1990) Primary surgery,vols 1, 2. Oxford University Press, Oxford18. Holcombe C (1990) The need for a Chair in Tropical Surgery. BrJ Surg 77:3–4World J Surg (2010) 34:2269–2271 2271123

The Academic Discipline of Tropical Surgery

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The Academic Discipline of Tropical Surgery

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