EDITORIAL MISCONCEPTIONS, MISCONSTRUCTIONS AND MISCONNECTIONS: THE VISAGE AND FATE OF MIDDLE LEVEL SURGICAL MANPOWER IN WEST AFRICA.
In present times and in different countries of West Africa, due to the paucity of appropriately trained personnel the availability of several specialist services does not go beyond the immediate city dwellers. The result is a palpable sense of urgency to extend the benefits of modern surgical practices to the ever increasing population especially in rural communities which are characterized by poverty and almost nothing associated with modernity including poor hygienic and public health practices and near cultural acceptance of mixing what is starkly native and unscientific with that which is avowed orthodox and scientific medicine.
In this situation as captured in Shakespeare’s Measure for Measure, “The miserable have no other medicine; only hope”. The West African College of Surgeons became “this hope” by its own initiative in outreach programmes and encouraged by requests from Governments in the subregion, it supported the rural extension of organized scientific surgical practice as a way of improving people’s general health through greater access to surgery. The response was translated into the training of middle level surgical manpower, middle for want of better and discriminatory appellation to express its scope and the quality of non finality in surgical decision- making ascribable to the associated diploma or certificate.
Having seen the success of similar schemes in other areas like Anaesthesiology, Otolaryngology and Ophthalmology, there is a tendency for Governments to see wisdom in middle level surgical personnel as a sine-qua-non for promoting and extending safe surgery among rural populations. There is also a tendency for Governments in West Africa to fast track the development of the middle level manpower cadre as a means of attaining improved rural health care on the assumption that persons so trained would remain and serve in the rural community. The expectation by Government is that the middle level specialist will act as extension surgical service provider where there are no surgeons as obtains in the rural community. The former is a misconception of the idea while the latter is at best a misconstruction in the design. Also the uncertainty or even the absence of commensurately improved standard of living highlighted by inaccessible road networks, unreliable transportation and ruinous schools would discourage the acceptance of rural posting by the new-make surgical specialist. It is a misconnection in the plan that fails to appreciate the fact that improved and quality health care does not reside exclusively with the organs of the Ministry of Health; there is a sizeable burden for those Ministries in charge of roads, housing, transportation, water resources and education. The point is often ignored or not reckoned with that the universal quest for civilized living incorporates easy access to literacy with a purposeful general education and improved standard of living in all its recognized indices.
Due to the disjoints arising from the misconceptions, misconstructions and misconnections in planning and execution the results expected become elusive as the new-make surgeon for his benefit and future welfare would want to practice and dwell in the city in the context of Shakespeare’s Richard 111
“Plead what I will be, not what I have been
Not my deserts, but I will deserve
Urge the necessity and state of times”
Opposition to the scheme derives its strength from the fact that the proponents focus on the immediate advantage of having more specialists available without addressing the sustainability and reasoned scope of the programme which calls for intuitive management of the various lapses. The training institutions and Colleges will provide good curricula of studies and monitoring of standards attained but it does not behove them to address the conceptual shortcomings inherent in the philosophy of the scheme.
The recommendation is to develop middle level surgical manpower, clothe it with the right professional garments but harness and project it in its right proportions by appending necessary and guiding norms in an environment that enables satisfaction for both the new-make surgeon and the population served.
Professor Reginald O. Ofoegbu
Chairman,
Editorial Board,
Journal of The West African College of Surgeons.