FEB-C-9
BEGINNING
THE DAY WITH A RUN,
I
PROCEED TO A THEATRE DAY OF UROLOGY,
GOITER,
HYDROCELES, AND AN ELECTIVE C-SECTION
FOR
A GENERAL SURGERY TOUR DE FORCE
Feb. 26, 2002
I have headed out on a brisk solo run as the sun was rising through the tropical thunderheads and the broad sweep of the green rainy season profligate growth contrasted remarkably with the sandy hard packed laterite pseudosoil of the eroded road along which I ran jumping potholes. How anything at all is able to be grown in the organic nutrient poor desert substrate of African earth is amazing. But there seems to be enough to be grown with labor-intensive care and store-bought fertilizer making an amazing difference in what the maize fields look like. The size of the plots is limited to what one person can comfortably till with a hoe, a device once made of stick and stone, and now imported from China in very low quality steel, such that the more primitive and heavier implements last longer. I see women and children heading out to the fields as I pass on my morning run, and they look on in amazement and glee that I should recognize them with a wave and a few Tumbuku words. Imagine that! There are Wazunga who expose their legs in short running shorts, and have such a surplus of energy, that they can squander some of it in a purposeless run from here to there and back again! Whatever for?
The daily calendar of events, in contrast to that which you see here recorded, might read for Feb. 26 for them, “Get up when rooster crows, fetch water, hoe corn, pound, cook and eat Nsima, go to sleep when sun sets” ---the same entry for every other entry in any calendar of any other month, for all the year around—at least in the non-drought times when there is anything surviving to be tilled at all. This rather monotonous schedule of events is repeated mindlessly, but necessarily, every day, as a baby is wrapped around the back or swung around to the side to grasp one swaying breast. The chitenga that holds the baby is in contrasting colors to the head tie, which is wrapped around the head to shield from the overhead sun or rain, but also to cushion the load that is balanced there—either a pail of water, a bundle of nsima, firewood, or simply the hoe—the emblem of office for the 83% of the Malawi population engaged in subsistence agronomy in that stingy poor ground, that must be hoed and planted, but erodes and turns to barren concrete if neglected.
As barren as that soil would seem that must produce to keep the body alive, the womb must also do its part to yield its produce to keep the family hopes alive. A young woman is barren if she has not produced within a very short time of puberty, and there are all kinds of further restrictions put on that reproductive activity that assures her place in this society even more than her slim possibility of an education. Primary schooling is said to be universally guaranteed, and access to secondary education is supposed to be also universal, but at a cost in school fees (about 1200 Kwacha per semester—more than the fertilizer and hybrid seed each of which are necessary to stay alive, a more primary instinct than getting ahead, which is a luxury for few.) So, fewer than a quarter of the eligible young people manage the secondary school—and after all, why should they? The schoolmaster’s maize plot is very well cultivated, but not because he has been wielding a hoe. His students are coerced into what might be charitably called “work/study” courses, in which horticulture on the personal plot of the teacher seems to be a higher priority than three or more of the “R’s”. So, you can hoe corn directly from your hut in the morning, or run to school after paying your fees, and wind up in the adjacent plot hoeing a little later the same day—and bearing surviving children is a much more obvious mark of success in the society. After all, the President of the Malawi Republic, Muzula, has never gone to secondary school. A Moslem, he achieved power the old fashioned way, according to the locals whom I have asked, “By money, magic, and manipulation.”
If you are not part of the 83% in the precarious position of growing just enough food to feed yourself and whatever burgeoning family you may be producing at the same time, a chancy operation, dependent upon wind, water, weather, whims and whatever either thieves or animals steal from your fields after all your labors, you can get a salaried position—and health care is about the only paying proposition around here. If you are a woman who has made it through school far enough to get a position on the hospital staff as a health care worker, you will have a secure environment to eat, and now can sit back and forego any manual labor in the fields, and enjoy your consumer surplus in excess calories. This is abundantly evident at the Chapel service and rounds this morning.
As I returned from the run I had made along the Tusa Road, dodging around eroded washouts around oxcarts, and being pied piper to a whole train of barefoot kids running in partial primary school uniforms behind me trying to keep up, but subject to fits of incapacitating giggles, I came into the hospital compound to view the very sharp contrast between the physical image of patients and staff. The patients were emaciated bony scarecrows, three standard deviations in weight lower than the norm for their height, swathed in chitengas to conceal their superficial wounds or deformities. The waddling women of the nursing staff were bursting out of uniforms already several sizes too big, overflowing the charts above three standard weight deviations above their norm for height, and teetering toward the incapacitating problems of morbid obesity. I am seeing in vivid contrast the two extreme ends of the spectrum in malnutrition as a function of economic development, magnified in the health care setting in which it is so apparent. No wonder my solo running excursions are looked upon as something from some other planet! Am I not wealthy enough to afford to exert as little as possible in a sedentary role while others serve me excess calories?
NUTRITION AND
DEVELOPMENT:
FROM STARVATION TO
OBESITY
I had been asked to write an editorial on African “Nutrition and Development” for the journal Nutrition, the same journal in which I had been pilloried for experimenting on natives in the Congo by trying to treat their hypothyroidism with consequences foreseen and unforeseen that should have been written into a US IRB-approved “informed consent.” You may remember the controversy that attended the pre-publication of my thesis, and has been followed by nothing but praise for a landmark study post-publication, the subject of the “Author’s Editorial: Advocacy in World Health,” which I can furnish on request. A second set of authors in South Africa viewed with alarm the accelerating epidemic of obesity, hypertension and diabetes in the developing areas of Southern Africa, a bounty that has not yet reached here, except in such isolated and outside-supported employment oases as this Embangweni Hospital Mission Compound and other sources of salaries supported by outside donor foreign aid. I pointed out that the highest risk groups for this “New Plague of Malnutrition” on the other end of the spectrum of starvation was obesity, now endemic in health care workers (see attached.) The odd part of it is that the workers themselves find this preposterous, and take their rotund corpulence as a sign of brimming over good heath and a status to be emulated. As Diane Downing had once said of a remark she was most annoyed to hear when she returned to Congo after a furlough in which she had gained thirty pounds, “We are so glad to see you back and with such a ‘good body!’”
The flagrant obesity and sedentary lifestyle is a mark of having arrived. Having escaped the dreaded scourge of deprivation, and also quite obviously not afflicted with “Slim”—the wasting disease that is the very apparent new scourge associated with an epidemic as superficially obvious as are the lesions of Kaposi’s Sarcoma. A married woman can flaunt the fact that she has someone supporting her in the manner to which she would like to become accustomed, or, if independent, can go her own way into caloric surplus. So, they do not understand why they should not be considered role models of perfect health, weighing in at something over any US life insurance tables of metabolic danger. They are the counselors of nutrition and health practices to send to the school children to show what they might yearn to become. As significant as the editorial opinion was when I wrote it (and it has been proofed in galley, so it should be published by now) it is even more glaringly obvious here in Embangweni Mission Hospital compound. So, I made a copy of the editorial to leave behind here and will append it as an appendix to this chapter Feb-C-9.
WITH AN ENGLISH
SONG FOR OUR BENEFIT
AS VISITING GUESTS
IN THE HOSPITAL
REQUIRING
EDIFICATION IN OUR OWN LANGUAGE
Although they may have been unaware of the gratuitous advice on how I might recommend they change their health behaviors, which did not prevent the choir from putting together a special song, in English, to help celebrate our being here. It was sung to a swinging rhythm and a chorus of “Oh, Lord, Save Me,” and then a litany of sins they had put to music. The various themes were: “I was a ….Womanizer, Drunkard, Drug-Taker, Fornicator, Chain-Smoker, Gambler…etc” followed by an emphatic “Sure!” but all suffixed with an assurance that there was still hope. I do not know if I was supposed to stand up and say, “Thanks, I needed that!” But, then again, I did not furnish them the editorial appended for your review either!
MORNING REPORT:
MAMA CHIMA
DELIVERED TWINS, ONE BREECH,
BUT NO BIG DEAL,
SO NO PHYSICIAN NEED BE NOTIFIED
In the litany of new patients, events, deaths discharges that had happened overnight, I heard in the report that several new patients had been admitted with malaria, treated, and a couple with meningitis, started empirically on the new ceftriaxone protocol made possible by my bringing in the drug, all of which were treated by their “Syndromic Treatment Protocol”—unconfirmed with any laboratory testing which may often (or, usually) be unavailable. So, straight out of the book (MSTG-94) the Malawian Standard Treatment Guide, most of the patients, even diagnostic dilemmas, were started on treatment, and my role is only to further differentiate those who did not respond to the first line treatment. This was the case for one man who came in obtunded, and he was treated for cerebral malaria with quinine and S/P the name they use for Fancidar. I can think of three reasons for the onset of a foggy mentation two of which are treatable and the third not, so it would be worth finding which of the first two might be there problem, leaving the third for the fallback residual of no therapeutic concern: 1) cerebral malaria—but if he does not improve on treatment, how about 2) meningitis—how about an LP? (Lumbar puncture and CSF examination) and 3) AIDS cerebritis. The latter does not need specific testing since it is not specifically treatable, and our job is to find and fix what we can make a difference in intervening.
Then, as you can see from the heading above, Mama Chima went her own competent way and did better than any of the physicians might possibly be expected to do—I chief among them—so I am glad I was not called for what she pulled off in yet another set of twins she popped into the incubation room. Perhaps the students might have benefited as observers, but we will run them through a lot of good things to see as well.
The Matron passed out, with a great ceremonial flourish, a new hand towel to everyone involved in patient care—including me, and George, so we will have to remember to return it. The accompanying caution is that this was not to be used as a chitenga, but as a personal hand washing aid, to avoid everyone washing his or her hands, but then returning to the same towel—a bad infection prevention technique. So, a whole bail of new hand towels was parceled out to each of the personnel on the different services.
AND, NOW, TO
THEATRE,
TO PERFORM AND TO
TEACH OPERATIONS—ALL BUT ONE—
OUTSIDE MY
SPECIALTY FIELD
An older man named James had been referred to me in clinic the previous day as a knowledgeable fellow who knew about hospitals since he had worked since 1942 in a government health center. But, he was solidly obstructed, and had been catheterized multiple times, with the last time being a resignation toward leaving the Foley catheter in place for a week until he could be referred. I had found an enlarged but soft prostate obstructing his bladder neck and outflow, with no evidence of hard nodularity that might indicate cancer. He understood the procedure proposed, and we had him come to theatre with Dr. Ngere and I since at report I had suggested he should learn to do two of the operations I had booked today neither of which he had done and only one of which he had seen. So, he did the first prostatectomy of his life with a non-urologist assisting him.
We made a retropubic, preperitoneal approach to the hypertrophied bladder, and entered it with the liter of saline with which it had been distended by the foresight of Mister Tembo. We put guy stitches in each side of the mucosa, then exposed the bladder neck from the inside (“transvesical.”) I made the mucosal incision with cautery in the bladder over the much larger prostate lobe on his side of the table, and had him feel the plane as I wiggled my finger under the mucosa to enucleate the lobe of the prostate. This happens by feel so that the others could hardly appreciate what I was doing, when I swiftly popped out the right lobe of the prostate and had him repeat the same maneuver on the left. I tried to get him started in the right plane, and then encouraged him to sweep his finger around the lobe to free it up and deliver it, using caution not to detach the urethra. He was perhaps a bit timid at first, so I helped him develop all but the last part of the prostatectomy, and then he popped it out. The prostatic cavity was empty when we peered down into it using the light from my new small Petzel Head Lamp. I then saw that he would have a difficult time suturing the mucosa in the confines of the bladder filling with blood and in the dark under the pubis, so I passed the catheter and blew up the balloon to tamponade the bleeding and to seat the mucosal rent down in the bladder neck. It worked like a charm. We carried out a three layer water tight bladder closure, and had an irrigating Foley catheter in place, so that we were able to complete the procedure with much less effort than getting an IV started in the patient before the spinal anesthetic took in twice the time of the operation.
We sent the patient off to the ward with the caution that the inflow of water (I had suggested they used water instead of the more expensive sterile saline) should equal what came out until the fluid was clear and had no clots. We then turned to the next patient—one that I suggested that we would not need to look up in any book written by any family physician since I was rather sure I knew how to take out a goiter.
Mrs. Malwa is how this patient was named in the chart, and everything about her had to be special—she did not stay in the hospital overnight before the operation, so that the nurses could be sure that she was “starved” (a much more rational term than NPO) and went home to be with her husband, a much more comfortable quarters. Her husband is the head of the PHC program here, so she has the status reflecting his role and would be a VIP patient in a “private room” where she was planning to play the sick role. Recall that in Mindanao the patients on whom I had done thyroidectomy could rarely be found the day following operation since they were doing well and went out. It seems she had planned to spend some time in bed, not even wanting to get up to pee, such that the nurses catheterized her and gave her “Pethidine” (the brand name here of Meperidine, which is our “Demerol”) for discomfort (Always minimal after thyroidectomy) since she claimed it was uncomfortable to swallow anything pills included.
Despite both Ishmael (clinical officer) and Dr. Ngere (Medical Director) claiming to be “scared to death in the neck” never having seen nor heard of thyroidectomy and rather anxious to be this close to one which I had encouraged them to do while I was here to help, the left hemithyroidectomy and isthmusectomy went smoothly and without a hitch. I noted that the halothane hose had become disconnected during the closure, so that the patient was more than ready for extubation, and proved that she had good cord function by hollering high notes when delivered to the ward. She is now lying there like a princess in her private room receiving visitors at her accoucher—in the same period that the Mindanao patients are climbing mountains on their way back home. She is fine. But, what may be more important, both Ishmael and Dr. Ngere have found out that it is possible to get in and out of the neck with minimum damage and with a very carefully planned operative dissection focused on the preservation of both parathyroid and the nerves that control the larynx. I told them I would go out looking for another goiter for them to do, perhaps even larger than this one and that they might do more of it with less assistant help than they had had with this one. I had seen a man walking the roads when I was running at dawn, and he was not a patient but a passerby outside the hospital on the Tusa Road—or else I would have stopped him and encouraged him to part with his WHO stage III goiter.
We debrided the deep plantar fascia of Mrs. Tembo who had stepped on a stick and developed a gangrenous deep plantar fasciitis. I had seen her in clinic and admitted her, since she would have progressed to amputation level gangrene without intervention and she is rather fragile anyway. She is in later stages of AIDS and needs local control of this before it makes her systemically septic, something I already have two examples of on the ward already. So, Mrs. Tembo was debrided—a patient who has a family claim on the MacLean’s since she Had Once worked for them, so now she is being fed by them, and she is going to leave three orphaned children to them shortly.
We then did hydroceles, with my assisting Ishmael in doing this operation so that there would be a core of non-physician operators at Embangweni if there were no doctors here who felt comfortable operating. This marks a milestone, since if I add this patient to the thyroidectomy, I have now just done my two first patients in theatre who are not HIV test conformed positive! The only reason I can say this is that these two patients had no reason to be tested, so their HIV status is unknown, but to date, all the problems I have encountered that should be straightforward surgical staples are complicated by the presence of the HIV virus and its devastating effects on host immune function
With a good day of general and subspecialty surgery behind us, we left for lunch after I had checked James, the post-prostatectomy, and he was doing fine with irrigation fluid flushing clear, cranberry-juice color fluid. When we go tot lunch, John Sutter my medical student came to report that the patient I had just checked was not draining at all and his scrotum and penis had swollen up very large. When we trekked back over to look, it was true. In the short interval since I had seen him, he must have dropped a clot into his catheter and it gave enough pressure in his bladder to leak water not saline into his scrotum. This is painful, since water is hypotonic. In fact, when people demand a shot from me that I am sure they do not need, I do not use saline, which is simply absorbed, but water, which stings. So, he had a scrotum full of water. We raised the swollen member and irrigated it clear. Although I never saw the offending clot, the irrigant continued clear from that point and we can stop the irrigation now since there appears to be no more bleeding in the bladder So, despite this rather mysterious transient complication, the first of what looks likely to be quite a series of prostatectomies has turned out to be uneventful in recovery. Some that may be coming next may not be so forgiving since they may not be simply benign prostatic hypertrophy, but represent the hard and adherent prostate cancer that invades into things adjacent and sometimes metastasizes to bone.
I knew when it was time to quit since the “Noon Rooster” began to crow just outside the theatre door. Most of the birds around the guesthouse are in overdrive at dawn, but this one seems to be programmed on a different clock. Furthermore, we ran out of water to scrub with. There is a pump with a handle just outside the theatre door and a special person is employed to dance with this pump handle to bring water up above the scrub sink into a holding tank that runs out to be convenient for hand washing. This is batter than having a circulator pour water from a pitcher over your hands, but it was another payroll job in the theater management.
AS
A PASSING FIRST-WORLD VISITOR FROM CDC
SUGGESTS
A POSSIBLE MEGA-INTERVENTION:
AND
TOWARD WHAT END SHOULD WE BE WORKING?
We had an unexpected visitor wander by, a fellow who fell from another planet named the CDC in Atlanta. He is of Indian origin from Kerala, and had US degrees in statistics and prevention as employed now by CDC. He and I chatted briefly as he had with George and the others. What he was after in his tour was not understood by each of us as the same, but he had said he was interested in the VCT program and those few who had tested NEGATIVE and to follow them up, something already done to some extent. But, Betty Poehlman heard him say he was interested in putting those who are tested negative on AZT to try to prevent their getting to be positive. What? Giving each individual in this continent at risk a daily expensive drug rather than five drugs to those who have tested positive? Is there anyone who is interested in giving the population at risk (a half billion people in this part of the continent alone!) a daily drug to PREVENT AIDS spread? Right! What first world blackmail can this poor and desperate area of the world work to bring about that program? I had once marveled that with the advent of the birth control pill, there were more people on earth taking a daily significant drug who were already healthy, and not for the purpose of preventing a disease. That is probably not going to be a unique status in the future for that class of drugs.
Of those who are at most risk, probably the highest who cannot modify their behavior since they are unconscious at the time and profoundly antisocial in their very reason for using the agents are hard-core drug addicts who use mainline drugs through dirty needles. The next group at highest risk, it would seem to me, would not be the first world homosexuals, or other stigmatized groups, but—right here and now—health care workers—particularly surgeons working in a theatre in a small out of the way corner of highly AIDS endemic Africa with needles and scalpel blades and bone spicules flying around freely, and whose last dozen patients included only two who were not known to be HIV Positive, only because they had not yet been tested!
It may also be a program with an ultimate question as to why it is that anyone is working so hard at a doomed outcome when the many “Child Survival” first world grants to the Third World are questioned. Child survival in an intensely overpopulated area of the world in which there is manifest incapability of feeding or protecting itself is a question I would put nationally and globally on the very direct personal question of anyone who seeks to have a baby when they cannot feed, nurture, protect or care for it. That would be a contraindication to having a baby in an unsustainable personal setting; why are there large programs with the express intent of making sure unsupported children survive? Do they then say as well, that having survived, they will educate them through college or a trade school to make it possible for them to flourish and compete in an environment in which the redundant population may not be able to survive in competition with the beneficiaries of these child survival programs?
It gives pause to visit the compound of the Catholic Karunga clan, and see the dozen children with scores of offspring from the second generation of one southern Malawian import who has fond a survival advantage by aligning himself with the compound ex-pats and most of his children are now in some capacity serving as income-generating cooks, guards, odd jobbers for people who cannot remain here for a sustainable future for which his large brood depends. But is not this tribe, the microcosm of sub-Saharan African dependence writ large? There are many questions of mercy and its application in such settings as I find myself here, in the midst of both famine and a very virulent plague. The last line of an editorial in the New York Times reviewing food and rescue programs in the horn of Africa said a brutal and simple fact. “The truth is, that in most countries where many children die, it is in regions where women have too many of them.” The biggest and most successful of the clinical programs in Embangweni seem to be the maternity programs (well over 2,200 deliveries per year) and the MTCT program, to see that an HIV doomed mother does not give birth to an HIV + child half of the time—an orphan production program. An educated mother at least, and a caring family at most are the most effective child survival programs, and in the context that surrounds me that seems to me to be a fatuous dream.
DINNER
AND EVENING OUT,
INVITED
TO THE NEW FOLK MOVING INTO THE
POEHLMANS’
“OLD HOUSE”
Dr. Alex MacLean and his wife Kathy, and three children here with one on the way, and the prior ones to be home-schooled here in the coming three + years, had invited us to dinner. In true missionary round up fashion, we walked over with dishes and utensils at the same time an enormous full moon was rising, in the direction opposite the sky where we had spotted the “Southern Cross” (Cruzeiro in Spanish South America or Cruzado in Lusophone antipodes.) As well as the Mac Lean family, who are now living in the house that the Poehlmans used during their 16 months here, I met a young lady named Carrie Heyman, who was born in Louisiana, but had been poking about the lobe a bit since-having been a Peace Corps Volunteer in Burkina Faso (which I was near in my days in Nigeria when it was still Upper Volta.) She was working at westernizing the evaluation and accounting practices of the station on the periphery of the compound, moved deliberately outside the pale of the mission, so as not to stigmatize it for any who did not want to associate with the mission and its agenda, in a building built by funds from the Leesburg Virginia Presbyterian Church called “Tikoleraneka” The name means, in Tumbuku, “Let’s all do it together.” An equivalent word I happen to know in Ki-Swahili is “Uhuru”, or “Let’s all pull together in peace.”
As we were there, the Kennedys
poked their collective heads in to ask a request. Sarah had never seen her husband operate (remember, it is
unlikely to be operating as a pediatrician!) and she had never seen a
C-section. We have an elective
C-section scheduled, and this would be his swan song operation before going
back to an environment in which he is no longer the Director of his fate but a
resident, subject to the orders and whims of a Western chairman as to what it
is that he does next. So, I suggested,
that rather than having me assist Ishmael, the clinical officer, as planned,
(after all, I explained, this “big operation is really nothing but an “I &
D”—incision and drainage--) that he come in and do this as his final operation
in Embangweni (and possibly, ever?) And I would stand aside, only taking his
picture with Mister Tembo, the original middle-of-the-night team, operating.
So, one of the advantages of being the big fish (a title earned by a lot of hard work and night crawling) in this remote pool, is that you can have friends and family members come in and admire what it is that you have been doing and which they know about only as interrupted dinners or nights out of bed. I may yet have others come to join me who are not ordinarily in the “Theatre”, at least of this type, and they can see what happens when it is needed to happen—and, probably, choose to go back to bed!
APPENDIX
“NUTRITION AND
DEVELOPMENT”
[AN EDITORIAL
OPINION ON AFRICAN DEVELOPMENT
AND THE EMERGENCE
OF A SECOND PLAGUE
ON THE OTHER END
OF THE ECONOMIC DEVELOPMENT FULCRUM:
FROM STARVATION TO OBESITY]
NUTRITION AND
DEVELOPMENT IN AFRICA:
The hallmark evidence of malnutrition in the developing world is starvation, the tragic inadequacy of macro- and micronutrients for the energy requirements of a majority of some populations. It may be a short, brief leap in perceived economic development to obesity, the characteristic malnutrition disease of the developed world. The meta-analysis of trends in Sub-Saharan Africa published in this issue of Nutrition by Walker, Walker and Adam examines the rather abrupt nature of this transition in energy imbalance in the process measured as development by most economic indicators. As many diseases as follow in train behind the underlying debility of malnutrition, it is well to look ahead to the spotty nutritional over correction occurring in developing world populations to project what further illnesses are becoming more prevalent following the epidemic of noveau-obesity. The burden of illness that follows this new wave of malnutrition is much more costly in terms of health manpower and technology investments in single individual's care, as the model of any first world hospital filled with consequences of metabolic, cardiovascular, CNS and renal degenerative disorders would predict.
It is important to emphasize that “third world” is a descriptor of populations living both within and outside any political border and reflects much more coercive social, economic and cultural motives and their stigmata than is reflected by a passport. Economic transitions occur much too rapidly to have their consequences attributed to genetic change—indeed, many of the changes noted are intragenerational, and distinct from the aging process. This genetically “given” status is actually encouraging, since it suggests that the acquired abnormality may be based in learned, and unlearnable, behaviors, an epiphany, which is actually empowering to medical and public health practices of prevention.
One model of coerced transition may be the tragedy of African enslavement over the centuries preceding this millennial pause for historic reflection. If Africans were taken from their home environments and cultural practices and transshipped to the new world for their labor, the few generations that have passed since this practice was stopped cannot account for the remarkable difference in the incidence of non-communicable diseases prevalent in the new world setting and nearly unknown at their origin only an evolutionary eyeblink before. An African-American investigator has published (1) the hypothesis of why, for example, black citizens of Washington DC should have a rate of hypertension, diabetes, renal failure, stroke and certain cancers that is several times higher than that of their neighbors of non-African origins, while such conditions were rare to non-existent only four to six generations ago in an African setting. The harshness of the Middle Passage in the slaves/molasses/run triangle may account for this as an “evolutionary knothole” through which this unnatural selection occurred, if the tragic losses of this harsh traffic differentially favored a “stingy gene.” Such a hypothetical gene or some combination that conferred metabolic characteristics that gave survival advantage though the conservation of calories, salt and water might be accountable for the new rash of metabolic disease in changed circumstances of mineral, energy, and foodstuff abundance.
The authors’ evidence in their review of recent changes in urban African morbidity might be used to postulate that the whole of the Sub-Saharan population of Africa may have been strained through a similar nutritional knothole, through the less geographically discrete and historically more protracted process of high infant mortality and differential death rates from diseases when starvation is co-morbid. Rather than blaming a bad deal of the genetic deck, it seems there might even be an innate protective effect, since obesity, hypertension, diabetes and stroke rates have soared, but another “big ticket” first-world plague has lagged behind: coronary heart disease, thankfully, has not kept pace, even as the other diseases bypassed the rates in Europeans in similar environments. Their warning, however, is as dire as the predicament is inevitable: although currently overshadowed and retarded by the infectious plague of HIV/AIDS, that, uncontrolled, is holding back development in much of the third world, and is pulling some emerging economies back toward the more primitive nutritional patterns, the impending rise of the coming plague of first world-pattern cardiovascular disease will be an even more crushing burden
It is refreshing to read an honest appraisal of conventional wisdom—which assumes that we have, or are soon gathering, enough information to make major efforts at prevention eradicate the big killer first-world diseases as effectively as we have controlled, say, smallpox. As nebulous a risk factor as is called “life style” seems to be correlated with a number of diseases, and is well worth working on to attempt to reduce some risks. But the authors go on to state a politically unpleasant, if correct, fact: we understand very little of the majority causes of coronary heart disease and breast cancer and even such an apparently obviously preventable condition as dental caries. All around our world, the environment is changing much faster than any genetic drift could occur. Just at the time we have made an enormous investment in the human genome project, we might come to the realization that, at least with respect to nutritional balance, a lot more of our disease burden is Lamarckian than Mendelian. We need to look up from our micro-analytic preoccupations and take the long view (2), and such meta-analytic reviews are helpful.
Other microenvironments have been examined as suggested laboratories of the often unanticipated downside of development.(3) One example that shows the economic dislocation of sudden passive wealth has lead to the world’s highest adult onset diabetes, hypertension and renal failure rates within a generation of the phosphate mining exploitation of the Pacific Island of Nauru, the UN’s smallest member state, for now among its wealthiest per capita, and with a population being eroded as much as the mining of the island’s base is by this recently acquired morbidity. (4)
In a comparative study of populations within Mozambique over time, Maputo province had relatively good records a century ago showing essentially no evidence of hypertension and its consequences in this relatively urban province, in which now the leading non-infectious cause of death in adults are these same hypertensive consequences. (5) This might be a lesson to some of us attempting to replete certain micronutrients, through vertical programs in rural areas such as Nyasa Province in the same country where most of these hypertension consequences are still rare. Promotion of, for example, iodized salt, is clearly intended as a means of combating iodine deficiency, but it may not be seen (perhaps because it is too obvious) that it is first of all a social marketing--of salt. In a population that has been chronically short of both, we should monitor not only the laudable reduction in goiter and cretinism as the benefits we seek, but also the changes in rates of blood pressure abnormalities and perhaps the start of other evidence of urbanization patterns of morbidity, reflected from the century earlier warning from Maputo Province and the onset of possibly preventable epidemics associated with development. Untoward consequences of medical relief and rehabilitation programs should be looked for and honestly reported, even while the laudatory objectives are so easily and rapidly reported. (6)
No one should be advocating a retro-dedevelopment, much less celebrating the health advantages of destitution from the privations attending famine, war, overpopulation pressures or economic oppression. “Development”, however is usually assumed quite comprehensively (unfortunately, by many economic advisors,) summed as the iteration of the measurable data of consumption. Consumption of increasing numbers of resources in health care might be viewed as a positive marker of development (particularly by those who receive the benefit of these services—and lest it be forgotten, these nearly always include the professional providers), but the need for such services should fit on the debit scale in such a meta-analysis of nutritional development, for which focus the authors are to be congratulated.
Is it the role of healthcare personnel and health educators to point out such tradeoffs that should be mitigated in any development program? Some clearly think not (7, 8, 9) and that such “collateral damage” should be relegated, at best, to other specialists. But, it seems, at least in Southern Africa, that the very health care personnel who should be the foot soldiers of this preventive program, who are the most embedded in the culture, (10) are those most severely afflicted by these “diseases of development.” A campaign in the Republic of South Africa to send public health nurses through the schools to warn against the problems of obesity and in case finding for diabetes and hypertension had to be called off, when every single one of the experienced public health nurses (thus, employed professionals) who pitched up to be sent out on the campaign was, herself, morbidly obese! (11) Many of the surprised health personnel did not understand why the preventive program would be contradicted by its very emissaries. It was explained that obesity, far from a stigma, was part of the desiderata of development, like a big house or a motorcar, a mark of achievement, a presumptively apparent negative serology in the context of the dreaded “Slim,” and evidence particularly for a woman, implying a man who cared for her, or at least a disposable income, invested in her overconsumption and underexertion.
Such cultural blind spots may have been prevalent in prior decades of first world overachievers, who were really only certifiable as excelling type-A executive class after their coronary bypasses. First world hospitals boasted about the superior high-technology care invested in such individual cases of preventable disease. These may be first and emerging third world res ipsa loquitor cases of health professionals in transition, dazzled by the immediate economic and technologic numbers, turning blind eyes over the downside of development and the untoward consequences of “advances” in nutritional development and health care.
Glenn W. Geelhoed, MD, DTMH, MPH, FACS
Professor of Surgery
Professor of International Medical Education
Professor of Microbiology and Tropical Medicine
George Washington University Medical Center
Washington DC