Surgery in rural areas: from simplicity to multitasking

If you are an American soldier, shooting at foreign nationals in their own back yard, and they happen to shoot back, it must be comforting to know that after a brief satellite call, one of your private defence contractors can have a fully functional intensive-care unit with four respirators set up within a couple of hours. While you are drifting in and out of consciousness on your respirator you might consider that your country has spent a defence budget that would not only put a few men on Mars, but might have maintained the health services of any of the 30 poorest countries for several thousand years! That is: the health budget for those countries can be maintained at its current level for as long again as the Gregorian calendar has been counting AC years; the middle ages, renaissance, reformation, modern times all included.

Most of us have to make do with simpler means, and the poorer (or economically challenged) the country is, the less budget you will have available for each patient, and the more creative you will need to be.

In rural areas, Funding and Communications (including transport) are often the most diffi-cult. Patients must walk or be carried for several hours, even days, to reach a health post, and will probably have used up all their available funding to reach there. Without a large support group or extended family most would not even attempt the journey, and it is worth considering the discus-sions that must have gone on before such an arduous journey is undertaken. I suspect that for most isolated rural communities, the various forms of western (as in occidental, not wild) surgery is an important reason they might attempt such a journey.

Once the patient reaches a health post offering western medical services, they may well find the required expertise or facilities are not available, so they must travel further if they are able. To finally end up in an understaffed and overstretched central hospital.

It makes sense to try to maintain some form of surgical services for common and simple condi-tions in the rural areas, and to train available personnel in those procedures. Notwithstanding the chronic desires of the WHO to think only in prevention, all but the most for-tunate of citizens will still at one time or another require curative medicine or surgery. A child with a broken arm or strangulated umbilical hernia will not care that effective vaccines prevented her from ever having measles, whooping cough, diphtheria or polio; she just wants that arm fixed or the terrible stomach pain to stop.

So what can we offer in the rural setting?

1. Keep it simple – simple instructions, simple procedures, simple instruments,
2. Keep it safe – effective selection of proce-dures and patients,
3. Maintain short lines of communication to larger hospitals,
4. Make use of telephone or internet where available for information and consultations,
5. Programme regular visits by specialists to see problems and provide further on-the-job training.

All this is of course nothing new. It has been applied in Malawi since the early 60s when my father was for a time the only surgeon in the country, long before the medical school was set up. In spite of an impossibly busy surgical schedule at the Queen Elisabeth Hospital in Blantyre, he still managed to find time for regular district visits around the country, teaching and training registrars, clinical officers, tropical doctors and district medical officers, provide advice and plan-ning for the Ministry of Health in the evening on his way home. He also ran a small farm, repaired the generators, windmills and cars, and on the odd weekend off would drive his large family to Lake Malawi for a weekend’s fishing or to Mulanje to climb the plateau and peaks. Paying ‘quick’ visits to the district hospitals on the way, even on those outings. Multitasking was first defined shortly afterwards by the Oxford Dictionary (OED 1966) but that was probably a coincidence.