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Background: A Difference in People

Apart from parasites, tuberculosis, and a totally different nutrition, climate, and socioeconomic background, the way in which the patient presents to the physician will be altered by the simple factors of philosophy, gender, daily life, and the distance which has to be traveled to the hospital (Fig. 44.2). During the plowing and seeding season there is no time to go to the hospital; long distances may have to be covered and transport is not available. Problably less than 15% of the world's population have access to good health care. On the average, 30% of all infants in tropical countries die before the age of 1 year. In many countries, adult mortality has not been well studied: death rates are not accurately known. The outlook for survivors of childhood is often speculative, with no reliable statistics. However, one can state that of those who survive infancy, the majority do not live beyond 50 years. Strangely, if that age is passed, the likelihood of survival increases compared with more developed countries where the degenerative diseases, such as cancer, chronic bronchitis, restrictive lung disease, coronary thrombosis, and those other "blessings" of Western culture take an increasing toll. Attitudes toward mortality, life, and old age are no more standardized than diseases, and the ability of the doctor to treat patients will depend on understanding and acceptance of a different philosophical outlook, different priorities, and, above all, patience with different attitudes.

Even admission to hospital may bring more problems than it solves. Hospital-acquired infections are more severe in the tropics, and more lethal. Surveys show the considerable and very real risk of gas gangrene, tetanus, Pseudomonas, Proteus, and pathogenic enterobacteria in hospitals in the tropics. Even poliomyelitis, amebiasis, trypanosomiasis (Chagas' disease) and malaria (as well as hepatitis) have been transmitted by blood transfusion, and now there is AIDS.

To all these difficulties must be added that of language, not merely for the immigrant physician but even for those born in the country. The same skin color does not always cover the same language or philosophy. There are many hundreds of dialects and languages and even where there is a common and acceptable lingua franca (for instance, Swahili in East Africa and English in India), uneducated patients, confused by sickness and the fear of the unknown, do not always understand the questions. Moreover, their own customs may dictate an always polite answer, not disagreeing with the doctor's apparent opinion. The medical "history" in the tropics can be quite misleading and the patient's interpretation of the doctor's instructions for drug therapy may be equally erroneous. Studies show that sophisticated patients, well accustomed to the Western way of medicine in the United States or Europe, seldom take their pills or diets as prescribed. How much more confusing are the instructions given across a cultural gap often confused by the local herbalist, who adds his or her own methods and advice, occasionally incompatible with Western therapy (see Fig. 44.44).

Medicine in the tropics has many exciting problems, but also many frustrations.

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Fig. 44.2A-H. Patients do not come early for treatment. (A)This Ethiopian lady arrived with a large ovarian tumor in her abdomen: this picture was taken the day she first came to the hospital. (Courtesy of Dr. L. Richter). (B)This African from Zimbabwe had a swelling over his right shoulder which had increased rapidly during the last few months. The vertical scars on the tumor are the result of treatment by his traditional doctor. This was a large hemangioma. (C,D) Patients often eventually come to hospital because their deformity, whatever it may be, has reached the stage that it causes a mechanical problem. The appearance is often of less importance to the patient. This 5-year-old African boy had a deformed hand since birth and the third and fourth digits grew much more rapidly than the others. The hand was so heavy that the child had to place it on his shoulder while walking. The child was otherwise normal and no other member of the family was affected. Because of the delay, the middle and ring finger had to be amputated and together with the mass weighed 750 g. A further operation was necessary to obtain a useful hand. (Courtesy of Dr. F. Franceschi, Tanzania, and The Ethiopian Medical Journal.) (E) In some patients the condition is bilateral. The hand radiographs of an 11-year-old African child from Zimbabwe: the deformity is not quite so gross, but as both hands were affected, the disability was significant. (Courtesy of Ms. A.A. Whitemore, Harare.) (F,G) If left long enough, simple "benign" conditions can develop into something unusual. This 75-year-old African man had had a swelling on his fifth finger for about 50 years. The year before he went to the doctor it became septic and discharged white pus. The mass was quite hard, with skin stretched over it (F). Radiographs (G) showed that the phalanges were not involved, and that part of the homogeneous mass was calcified. The finger was amputated and the histopathology showed a lipoma with fat necrosis and calcification. (Courtesy of Dr. E Franceschi, Tanzania;, Histopathology report from Dr. K. K. Unni, M.D., The Mayo Clinic.) (H) Very advanced faciomaxillary fibrous dysplasia: the mass is almost the size of this Kenyan patient's head. (Courtesy of Dr. S. Malik, The Aga Khan Hospital, Nairobi).

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