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Indian Journal of Surgery, Vol. 65, No. 6, November-December, 2003, pp. 504-509 Personal Viewpoint Surgical care for the poor: A personal Indian perspective Tehemton E. Udwadia Emeritus Professor of Surgery, J. J. Hospital, Mumbai 400009, India, Head, Department of Minimal Access Surgery P. D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai - 400016, India.
Paper Received: September 2003. Paper Accepted: October 2003. Source of Support: Nil. How to cite this journal: Udwadia TE. Surgical care for the poor: A personal Indian perspective. Indian J Surg 2003;65:504-9. Code Number: is03109 ABSTRACT The appalling lack of adequate surgical care for the poor suffers on two counts: firstly our involvement and complacency with achievements in urban centres and secondly because of passive acceptance on part of poor patients and a disinclination on the part of the rural surgeons to document their experience. An effort is made to analyze some of the problems faced, progress achieved and what perhaps needs to be done. Special emphasis is placed on a medical education curriculum which embraces the needs of 70% of our population, on encouraging innovation and "research" by the surgeon who is in the thick of providing care to the poor, the implementation of human resources development and on distance learning. Surgical care for the poor is a neglected necessity all over the developing world and merits interchange and cooperation of all surgeons in all countries. Key words: Surgical care, poor patients, rural surgeon, medical education, innovations, distance learning, peer pressure, developing countries. Indian Surgery lives in a world of make-believe. Every conceivable agency, be it government, the media, the surgical profession, industry, is involved in a conspiracy and crusade to highlight our advances in surgery - the transplants, the by-passes, the replacements, the precision of investigative equipment and operative instrumentation. These spectacular advances are a matter of great national pride, and are on par with any country, anywhere. However, does this high-tech, high-cost, richly publicized progress reflect the true level of surgical care in the developing world? Having worked for over 30 years in a welfare teaching hospital I have tried to cope with surgical care of the urban poor. It is a myth that the poor are only in rural India. Well over 40% of all urban population is in a state of deprivation. Since 1972, convinced that diagnostic laparoscopy had an important role to play in developing countries, I traveled the length and breadth of the country and into neighbouring countries trying to convince surgeons of its utility, and similarly since 1990, of the scope and feasibility of Minimal Access Surgery. This paper is not an advocacy of MAS. However, MAS gives me the eye-opening opportunity to see and experience surgery in the small towns and rural areas of our country. Regarding there being two types of surgery, one for the rich and one for the poor it would be the ultimate in hypocrisy to pretend otherwise, for that matter in large parts of India and the developing world there is just no surgical care at all for the poor. On a subject, which has a variety of facets, innumerable documented facts and as many grey areas I would like to discuss: 1. The enormity of the problem. Enormity of the Problem The basic problem as also its solution lies in the quagmire of overall socio-economic growth and progress in India as all over the developing world. Health is just one aspect of this situation. The Preamble of the W.H.O. constitution states "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human without distinction of race, religion, political belief, economic or social condition". How very trite and hollow these words sound to those who work in health care in the developing world. How depressingly different are the true facts. Surgery is but one facet of the total health picture. Figures published by the W.H.O. show that India has 48 doctors (not surgeons) per 100,000 population as compared to 280 in the United States or 300 in France. The country has less than 12% of the minimum recommended hospital bed strength by the W.H.O., and of this meager bed strength 80% is in large cities, while 70% of the population is in rural India, giving a completely distorted and inequitable distribution of what, to start with, is a very low bed strength.1 There are over one hundred million cases of diarrhoea annually, which is not surprising when 40% of Indian households have no safe drinking water and 60% have no sanitation. Statistics are difficult to establish or confirm, but it has been documented that in the developing world surgically treated illnesses account for 10 - 15% of all hospital admissions, and sadly are the precise cause of 20% of deaths in young adults2 striking the community in its most productive years. Similarly in East Africa twenty years back only 14% of strangulated hernia and 11% of mothers who needed caesarian section received surgical aid.3 Hopefully all over the developing world conditions have improved over these two decades, but one does not need statistics to know that in every developing country an unacceptably large percentage of the population has no recourse to any form of surgical aid. While most of the urban population has access to surgical help, over 40% of even the urban population does not receive optimal management. After ten 5-year plans of our planning commissions and politics where do we stand? Government allocation for health is about 1.5% of our budget, our infant mortality rate is 72/1000 and maternal mortality rate 5/1000. We are still struggling to establish a chain of functional primary care centres where basic surgical care can be rendered, nowhere is there an adequate referral system to secondary care centres (which if present are poorly equipped and staffed) or to tertiary centres. It is unlikely that in the foreseeable future there will be a dramatic improvement in the government's involvement, because unlike caste or religion, health is not a vote-bank. As long as the rich, the powerful, have access to five star public or private hospitals for themselves, their families and their protégés, there will be poor incentive to improve health at grass root levels inspite of all the preaching and protestations. About 20% of our countries surgical work force live and work in rural India,4 in an endeavour to address the surgical needs of the 70% of our population, many of whom are poor, with no hope of surgical care. These surgeons work without basic civic infrastructure - power, water, sanitation, roads, and schools. Without recognition or financial security, without trained or qualified assistance, without adequate prior training and education in Medical Colleges to face the grim and diverse realities of coping with the heavy demands of surgery in all its variety in rural India, necessitating that they learn, as it were, on the job. With this dismal background of health care, can we hope to give quality surgical care to the poor? Contradictory as it may sound, the answer is an emphatic YES. I am confident that inspite of official apathy, or perhaps because of it, we are moving in the right direction. What has been done? When I started surgery 43 years back, the surgeon working in rural India was a rare and remote figure who continued working under unimaginable odds with the demeanor of a masochistic martyr. Thanks to workshops in diagnostic laparoscopy and laparoscopic surgery I was gifted the wonderful opportunity to travel and interact with surgeons all over the country and have experienced the exhilaration of a wonderful metamorphosis in rural surgery unfold over the last three decades. This has albeit been facilitated by the considerable improvement in basic facilities in several areas of rural India, water, roads, electricity, communication, schools. I have invariably returned from these workshops inspired and made humble by the quality, range and dedication of today's rural surgeon. The future of surgery in India as also of the surgical care of the poor lies in the proliferation, education, acknowledgement, recognition of this emerging genre of Indian surgeons who by dint of courage, capability, innovation, improvisation, sacrifice have given a new dimension and aura to Indian surgery. In an age where Professors in teaching institutions inculcate and urban surgeons in India stress the importance of sub and super specialization into pancreatic, rectal, breast and similar specialities ad infinitum, the rural surgeons has shown that for the vast majority of people and their problems the ultimate super speciality is general surgery. This rural super-specialist will trephine for an extradural, drain an empyema, suture a perforation, cope with a ruptured uterus, a compound fracture or a polytrauma. He may do this, sterilizing his instruments in water boiling over a kerosene stove, with an untrained anaesthetist using ether anaesthesia, with an unqualified nurse as his sole assistant, quite often with torn or even no surgical gloves.5 This is the picture of surgery for the poor in large parts of India. These rural surgeons are prepared to do this because they know they are the last bastion of the poor - beyond them there is no other succour. Their gains may be meager but their joys and rewards are bountiful and they may well ask their urban colleagues, a question asked 2000 years ago - what avails a man if he gains the world, but loses his soul? The heartening story is that their fold is rapidly increasing giving us hope there is light at the end of the tunnel. These surgeons who now account for well over 20% of the Indian surgeon force are by and large self sustained or sustained by charitable institutions, with meager or no support form government agencies. With increasing numbers and a self-confidence arising of an awareness of their national importance these surgeons are gaining in strength, asserting themselves by having their own Associations, their own conferences, their own Journal.4 A reassuring factor is that small town surgeons have not depended on outside agencies to implement innovation, rather have engineered advances based actually on their own efforts and experiences. They are fighting their own battles. Space would not permit an account of the innumerable contributions of Indian surgeons towards care of the poor - the Jaipur foot, easy to fabricate, low in cost, light in weight, perfectly suited for Indian conditions is the most striking example.6 A multi centre preliminary trial using indigenous mosquito-net cloth for repair of hernia has been reported.7 The cost of each piece of this mesh for an inguinal hernia would be Rs. 0.45, infinitely cheaper then commercially available mesh, and well within the affordability of any patient, seemingly with results comparable to commercially available mesh. Starting from a 7-bed Mission Hospital tucked away in a small town in Kerala a single surgeon took upon himself the task of curing infants and children of the stigma of cleft lip and cleft palate.8 Over a period of four decades the hospital has grown a hundred fold and he has single-handed perfected a technique over nearly 10,000 cleft lip and palate repair.9 Perhaps more important than the volume of work or the excellence of results is that almost every patient was treated at no cost to the patient with support from local, national and international funding bodies. Today this one time 7- bed hospital draws both patients and surgeons from all over to benefit from its large volume, technical excellence and its missionary charity. One N.G.O. body runs a fully equipped three operation theatre train (The Lifeline Express) as a mobile unit since over a decade, "camping" for several weeks at remote rail-heads and has treated completely free of cost several thousand rural patients. Sponsored by industry the Lifeline Express requires meticulous organization and the support of motivated volunteers and surgeons. In a similar vein other bodies have taken small single mobile theatre units into rural areas not reachable by train. Surgeons have innovated laprolift equipment out of towel clips, coat hangers, water pipes to permit the penetration of gasless laparoscopy to rural India10,11 and quality M.A.S. has been taken into small town rural India.12 The care of the patient with burns has been simplified and made almost cost-free by various methods like self-care13 and potato peel dressing.14 Innumerable similar innovations, which can be seen in almost every Taluka in India, are not flashes of genius but the inspired result of working over many years under conditions of necessity and deprivation. Some of these contributions are documented in a recent Special Issue of the Indian Journal of Surgery devoted to rural surgery.15 Nor are innovations in rural surgery India's prerogative. Similar improvisations are seen in almost every developing country. For example in rural Nigeria rain water is harvested in nursing homes for year around water supply, a charcoal furnace powers the autoclave, large windows which catch sunlight compensate for interrupted electric supply, all hospital equipment is fabricated by the village blacksmith, the rear wheel of a bicycle doubles as a haemotocrit centrifuge.16 The bane of the rural surgeon is having to work without the luxury of assistance by any trained personnel. There are just no trained anaesthetists, pathologists, radiologists, nurses, paramedical staff. Any "specialist" city surgeon would be hard pressed to repair a simple hernia under such circumstances! The surgeon hence has to train the local family physician or villagers to perform some or all of these tasks. Even in this vital area there is a distinct improvement. So far these surgeons trained their own staff their own way. There is emerging an element of human resource development in rural surgery by establishing a structured and reproducible education module of didactic and practical training of various levels of local "nursing" and para-medical staff depending on levels of previous education and practical competence.17 Cut out from the mainstream of academic surgery the rural surgeon has a difficult time coping with the rigors of his practise and keeping abreast of surgical progress, often the poor are short-changed by the rural surgeon's inability to keep informed. Two factors have contributed to resolving this problem. The Internet has made surgical literature and progress available to all surgeons, everywhere, reducing (or elevating) all surgeons to one common denomination. The second factor is the emergence of Distance Education as a training tool for rural surgeons.18 I quote: "The concept of Rural Surgery has developed during the past few years to make basic limb saving and life-saving surgery available within limited resources for those who have no access to it under their present socio-economic circumstances. Hafden Mahler, Ex-Director General of WHO labelled this type of care as `Essential Surgical Care'. Indira Gandhi National Open University (IGNOU) has tried to translate this concept into an academic exercise with an objective to materialise the concept of `surgery at doorsteps.' For a better understanding, the term `Rural Surgery' may be defined as the practice of need-based multidisciplinary surgery under resource constraints to make surgical care affordable and accessible to the community. Distance education has emerged out of the human need to learn amidst all types of constraints and adversities". The entire program, is fine-tuned to address specific educational requirements for surgical care for the poor, both rural and urban and a one-year course of Certification in Rural Surgery has been developed by IGNOU in collaboration with the Association of Rural Surgeon of India.19 What needs to be done? The 80% of Indian surgeons who work in urban India must urgently wake up from their obsession with the newest and latest to see the reality of the factual and complete scene of surgical care in India. It is time they got off their high horse to inculcate a sense of fellow feeling and oneness with their rural colleagues, to join with them as responsible partners in ensuring an acceptable even if minimal surgical care for the country. A prerequisite to do so would be an appreciation from them and the country of the role currently played by the rural surgeon in giving some surgical care to the poor. Our medical education system needs rethinking and revamping.20 It mimics established patterns from the developed world, where super and sub specialization is a norm if not a necessity. This inappropriate system relentlessly churns out specialists for a country where the need of 70% of the people is for general surgeons. Residents and postgraduates are offered no experience, information or guidance in surgery in rural India so that even if they had the inclination, it would be difficult for them to enter a world of which they are clueless and ignorant. In the process "general surgery" is made to sound like an indecent term, whereas as the way it is performed in all its variety by the small town and rural surgeon, general surgery is in fact the ultimate in super specialization. This form of education where there is total disregard for reality and national interest needs urgent redress. Our educationists must accept that the West is not the source of all knowledge and learning. We must build bridges with our neighbours in South East Asia and our colleagues in Africa, who share our problems, to learn from each other's experiences and innovations. One national magazine annually publishes a list of the "ten best" medical colleges in the country.21 This list has not substantially changed over the last several years, showering accolades on institutions which excel in meticulously mimicking the leading teaching schools of the West, no matter if a large proportion of their Professors and students migrate en mass. These leading institutions may be the pride and frontiers of our medical education system, but in all these annual "Oscar" nominations I have never ever come across any mention of, leave alone credit to the very few medical colleges established in rural areas like Sevagram or Karamsad which endeavour to give medical students a realistic education to cope with Indian life. The Government of Tamil Nadu is to be congratulated on a Government Order22 which encourages Medical / Dental colleges by private organizations only in backward / rural areas of the State to improve medical facilities in these areas. A follow-up on this move is eagerly awaited. As important as basic postgraduate education for the rural surgeon is an ongoing programme on continuous surgical education and updating, for the rural surgeon has, with discrimination, to integrate current advances into their rural practise. Attending conferences is at best a luxury only a few of them can avail of. Here is where technology in communication with the aid of distance learning can be an effective medium for constant information and updating. The certification course I.G.N.O.U. has with the ARSI course could be expanded to have an ongoing continuous education programme tailored to the requirements and conditions of rural surgeons.23 In similar vein we must have a national policy toward the education of paramedics for rural areas to fill a vital void in the support system for safe and efficient surgery. A uniform standard of paramedic efficiency would go a long way in implementing surgical care for the poor. The rural surgeon is subjected to heavy and at times unfair peer pressure. This is from two areas - their own senior colleagues as also from Professors in Departments of Surgery. Their senior colleagues try to inhibit and suppress the acceptance and implementation of new advances like laparoscopy in small towns on unfounded grounds. It has been shown for example that Diagnostic Laparoscopy is ideally applicable and cost effective in developing countries where sophisticated diagnostic methods are not easily available. The cost of equipment when spread over the patient load works out to Rs. 30/- per patient - an affordable price for a tissue diagnosis.24 This rejection of progress by peers is a negation of the growth of surgery, for surgery to be alive there must be progress, there must be change. The peer pressure from Professors is equally crippling. In several parts of India, laparoscopy is done with the use of atmospheric air. Adhering to guidelines formulated by Endosurgical Societies in the developed world these Professors and Heads of Departments frown severely on the use of air. I have for years advocated that for pragmatic progress in surgery in the developing world one must adhere to the concept of the 5 A's - Available, Affordable, Accessible, Acceptable and Appropriate.25 If CO2 cylinders have to be transported 200 kms over rough terrain to refill, the use of air would be available, accessible, acceptable, affordable, and hence appropriate. In response to a multi centre trial of a cheap indigenous material for hernia repair,7 the Professor and Head of the Department of Surgery of a Postgraduate Medical Institute wrote me to express his annoyance that this work was carried out in rural hospitals "without any prior animal toxicological study"!! Where do facilities for animal toxicology study exist - in a rural hospital or in a Postgraduate Teaching Institution? This form of hernia repair, on current evidence, cannot be advocated for general use, but do we not owe it to the national interest to give it adequate trial after laboratory study? If our teaching hospitals would take time off reproducing, parrot-wise, research done in the west and divert their energies to more pertinent and pressing national priorities, these Departments could work in collaboration with the rural surgeon giving the innovations and "research" of rural surgeons a more "scientific" base. Research that duplicates studies and does not relate to the health priorities of developing countries is unethical.26 I was particularly distressed to receive this Professor's letter of disapproval of this economical mesh repair because I on my part was wondering why National Awards are seldom given to innovative rural surgeons! Could this be because National Awards are usually recommended by politicians, industrialists and film stars, a group the rural surgeon is unlikely to treat? The Alma Ata report27 on primary health care emphasized research and evaluation by those providing the service. While the unavailability of modern technology has limited the scope of research in rural centres, it is still possible to conduct appropriate, "low-tech," and relevant research that is subject to an excellent study design, proper controls, and scientifically valid interpretations.28 Society must exert to enhance both the performance as also the accountability of the rural surgeon. However, it would be patently unjust and unfair to apply the same law for a large urban hospital as for a rural nursing home, cottage or mission hospital. For example there would be no option in rural India but to use unqualified nursing and paramedic staff to man laboratories, theatres, wards, x-ray Departments, etc. If the same laws that apply to urban hospitals were to apply to rural India every one of these small rural centres would have to close down or their surgeons face imprisonment29 ensuring that the law would effectively and completely throttle what little surgical care we have for the poor at present. The judiciary needs to wake up to the reality of rural India and pass legislation to help not hinder health care for the poor, accepting that some care is better than no care at all. The surgical care for the poor is an uphill and Herculean task, yet a task worthy of every ounce of our collective effort and energy. No one person, no one country can have the answers. It is vital all surgeons from all spheres of activity in the developing world from Professors to village doctors, as also those from all developed areas pool their concerns in this effort. If success is defined not by what one has attained but by the effort made in overcoming obstacles, just our sincere efforts in this cause would be by far the greatest triumph, the ultimate success story in the art and science of surgery - to ensure basic surgical care for all the poor. REFERENCES 1. W.H.O. Estimates of Health Personnel. 1998. 2. King M, Bewes P, Cairns J, Thornton J. Primary Surgery. Oxford: Oxford University Press; 1990. Vol 1. 3. Nordberg EM. Incidence and estimated need of caesarian section, inguinal hernia repair, and operation for strangulated hernia in rural Africa. BMJ 1984;289:92-3.4. Antia NH. Rural surgery in India. Indian J Surg 2003;65:66-7 5. Prabhu RD. Surgery in rural India. Indian J Surg 2002;64:376-7. 6. Mohan D, Sethi PK, Ravi R. Mathematical modelling and field trials of an inexpensive endoskeletal above-knee prosthesis. Prosthet Orthot Int 1992;16:118-23. 7. Tongaonkar RR, Reddy BV, Mehta VK. Preliminary multicentre trial of cheap indigenous mosquito net cloth for tension free hernia repair. Indian J Surg 2003;65:89-95 8. Adenwalla HS. Guest Lecture 1st World Congress of International Cleft Lip and Palate Foundation, Zurich. July 2002. 9. Adenwalla HS. International Update. Indian Society of Cleft lip, Palate and Cranio-fascial anomalies, Madras. March 2003. 10. Nande AG. A technique of abdominal wall lift. In: Udwadia TE, editor. Laparoscopic surgery in developing countries. 1st editorial. New Delhi: Jaypee Medical Publishers: 1997. pp. 329-31. 11. Deshpande SV. Abdominal wall lift. In: Udwadia TE, editor. Laparoscopic surgery in developing countries. 1st editorial. New Delhi: Jaypee Medical Publishers: 1997. pp. 326-8. 12. Ramakrishna HK. Taking newer technologies to the Rural patient. Indian J Surg 2003;65:38-43. 13. Antia NH. The soap and water treatment of burns. Natl Med J India. 2001;14:316. 14. Keswani MH, Patil AR. Bandages of boiled potato peels. Burns 1985;11:220-4. 15. Prabhu RD. Editorial. Indian J Surg 2003;85:17-9. 16. Awojobi OA. Rural surgery in Nigeria. Indian J Surg 2003;65:44-6 17. Banerjee S. Human Resource development in rural surgery: Developing the Paramedic training programme. Indian J Surg 2003;60-5. 18. Jena TK, Agarwal AK. Distance Education - A training tool for rural surgeons. Indian J Surg 2003;65:50-4 19. Agarwal AK, Jena TK. Multiskilling the surgeons through a distance education programme (Certificate in Rural Surgery) of `IGNOU' 8th Annual Conference of Rural Surgeons of India, Manipal, October 2000. 20. Nundy S. Difficulties of Surgery in the Developing World: a personal view. Lancet. 1999;353:21-3. 21. Bezbaruah S. India Today. 2003. pp. 36-8 22. Government of Tamil Nadu, Health and Family Welfare Department. Government Order (MS) No. 211 dated 13-8-2001. 23. Panda S, Jena TK. Changing the pattern: towards flexible learning, learner support and mentoring. In: Lockwood F, Gooley A, editors. Innovations in Open & distance learning. UK: Kogan Page Limited; 2001. 24. Udwadia TE. Diagnostic Laparoscopy - A 30 Year Overview. Surg Endosc 2004;18:1 25. Udwadia TE. One World, One People, One Surgery. Surg Endosc 2001;15:337-43. 26. Bhutta Z. Practising just medicine in an unjust world. Editorial BMJ 2003;327:1000-1 27. Primary Health Care. Report of the International Conference on Primary Health Care. USSR: Alma Ata; 1978. 28. Ajayi OO, Adebanowo CA. Surgery in Nigeria. Arch Surg 1999;134:206-11. 29. Tongaonkar RR. Scope and Limitations of Rural Surgery. Indian J Surg 2003;65:24-9. © 2003 Indian Journal of Surgery. Also available online at http://www.indianjsurg.com |
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