Learning from low income countries: what are the lessons?

Editor—Surgical services in the developing world are very different from those in the developed world. High patient load, limited resources, advanced stage of diseases at presentation, and limited number of surgeons (mainly owing to migration to the developed world) are some obvious differences. Although these unfavourable factors have a negative impact on surgical care, they have some advantages.

These include more opportunities to develop surgical skills, less litigation allowing bold decision making, ability to survive without practising defensive medicine, and more commitment from patients in the battle against illnesses. Although academic medicine and research in the developing world have hardly any support, a lack of resources and high case load promote new thinking and innovations.

Although transurethral resection of the prostate is widely performed in the developed world, open suprapubic prostatectomy remains the gold standard in the developing world, where glycine containing irrigant solutions are difficult to obtain.¹ We use sterile water (prepared locally at the hospital) as the irrigant fluid and have performed over 350 consecutive such resections without any deaths. Several years ago, low friction hydrophilic catheters were too expensive and therefore not available—a major drawback to popularising clean intermittent catheterisation in Sri Lanka. A catheterisation programme using ordinary Foley catheters (silicone coated latex), which are freely available, was highly successful.²

These are two examples of many improvisations that surgeons in developing countries use to provide effective surgical care to their patients. Large economic advantages of these techniques outweigh the minimal clinical disadvantages. It is important to realise the advantages of developing better surgical skills and cheaper innovations instead of very expensive technological advances to improve care for patients.