Inaugural Speech: Surgery in the face of low resources

1st International Congress for Innovation in Global Surgery

Inaugural Speech: Surgery in the face of low resources

Tehemton E Udwadia
Breach Candy Hospital, Mumbai, India

“The future belongs to those who believe in the beauty of their dreams”
– Eleanor Roosevelt

I am greatly honored to be invited to speak at the inauguration of this fantastic path-breaking conference of the cream of the world of academia, discussing Global Surgery.

When I read the list of participants and stakeholders, I felt like a rag-picker, talking to royalty. Today my heart is full of joy because this conference has made my dream for over 40 years come true. Having neither the wit, wisdom, nor authority, with all my effort, I have failed to make my peers, university teachers, and surgeons in the tertiary care hospitals see the real India, harken to the voice and pleas of the rural surgeon and rural population, to tweak their decades old curriculum to be more in sync with the needs of the country. This conference with its list of academia is the answer to my dreams.

I too am a city surgeon. I worked for 59 years in Tertiary Care Hospitals, and 31 years in a teaching hospital (Photo 1). The poor live not only in rural India, over 40% of the urban population are in a state of deprivation. My ward in 1971 (Photo 2) at the J.J. Hospital had patients on the beds, on mattresses between the beds, under the beds, and in the corridor. Lack of infrastructure, and paucity of funds for diagnostic facilities accounted for the backlog.

Laparoscopy was introduced into ward 19 of J.J.Hospital and into India in 1972 (Photo 3), not as a tribute to high technology, but to provide instant diagnosis and early treatment for patients in a hopelessly over-burdened ward. Not being able to afford an insufflator, I used a sigmoidoscope pump to create a pneumoperitoneum (Photo 4).

I found that this pump was far better for the patient because all cases were done under local anaesthesia and the slow inflation of the abdomen was more comfortable for the patient. Surgeons in cities looked down upon me and diagnostic laparoscopy with scorn, ridicule, and contempt. But surgeons in rural India who had neither ego nor diagnostic facilities accepted diagnostic laparoscopy and invited me for workshops. Diagnostic laparoscopy is affordable in developing countries (Photo 5).

I am blessed in my life. Thanks to laparoscopy, from 1975, I have been granted the opportunity and privilege of traveling all over small towns and rural India to try to spread the gospel of laparoscopy. In 1975 the word “global” was unknown – so I termed it rural surgery. Every visit I made to try and teach laparoscopy I invariably returned humbled, inspired, and educated by the quality of versitality, innovation, and dedication of rural surgeons. I realized that the future of surgery and the care of the surgical poor lies in the proliferation, education, acknowledgment, and recognition of this emerging genre that with courage, improvisation, and innovation has given a new dimension to Indian surgery. They deserve our respect and support.

In an era where professors in teaching hospitals inculcate the cult of specialization and super-specialization in their residents, the rural surgeon has shown that for the vast majority of their patients, the ultimate super-specialty is wide-based general surgery. This rural super-specialist will trephine for an extra-dural, drain an empyema, do a Ceaser, a perforation, and attend to a compound fracture. The steel of the rural surgeon is tempered in the furnace of want, deprivation, and necessity and these have inculcated in their strength and qualities of ingenuity, innovation, courage, and determination to face and meet all odds. Today rural surgery as I first saw it in 1975 has grown and advanced greatly with sophistication, training, equipment, finances
because the conditions of life and economy in rural India have improved so wonderfully.

I have all my surgical life been branded as an unorthodox, heterodox, irrational, experimental surgeon for starting diagnostic laparoscopy, using the mother’s saphenous vein valve to create a ventricular – jugular shunt, free of cost, (in place of the expensive Pudenz valve) for children with hydrocephalous, using and proving the efficacy ghee
and honey dressing for infected non-healing wounds, and several such aberrations.

After six weeks of training on homemade primitive simulators the surgical teal of War 19, JJ Hospital performed the first laparoscopic Cholecystectomy. Within weeks English surgeons condescendingly wrote in Indian Journals that sophisticated, surgery was inappropriate in developing countries and sadly, Indian surgeons wrote in the Lancet, questioning the ethics and denouncing the arrogance of surgeons advocating laparoscopic surgery in India. In surgery, the truth often starts as blasphemy. Laparoscopy is today practiced all over India, India is among the world leaders in laparoscopy.

Innovations by rural surgeons faced far greater problems. As Chairman/Editor of the Indian Journal of Surgery, I was proud to publish in a Special Issue on Rural Surgery an article by a few rural surgeons on the use of mosquito-net in place of the expensive imported mesh for tension-free hernia repair, at the cost of one cup of tea. Within weeks I was castigated by the Heads of Department of teaching hospitals for lowering the standard and reputation of the Journal by publishing a paper devoid of experimental study, comparative trials, blind studies. I wrote to all a one-line reply. It is easier to perform all their requirements in a well-financed teaching hospital compared to a 10-bed nursing, home in a tribal area! I got no reply. Today mosquito net is used in MLIC for hernia repair in Africa, South America, and Asia. I repeat, “in surgery, the truth often starts as blasphemy”.

After struggling physically and mentally over the quagmire of rural surgery with all its low resource constraints for four decades, I am convinced there is only one solution. The change must come from within each country. Without funding by the country, if necessary, with foreign aid there can be no implementation. The important message is that investment in surgical services is affordable, saves lives, and promotes economic growth. India must go the whole hog, reach for the stars, and start from scratch to create an equitable health system for all – self-sustainable surgery care from the ground
up. This utopian dream will not be possible in a few years – may take a decade or more. It can and must be done.

I have a good reason for my seemingly demented optimism. Within a span of eight short years (of which two years were lost to Covid) the Narendra Modi Government has brought to every Indian village water, electricity, roads, sanitation, schools, gas for cooking, banks, digitalization, internet, and even Rotary in a few places. Then why not add surgical care? I am sure the Modi Government has the vision, strength, and resources to provide surgical and all healthcare to every part of the country. This would be a humongous government undertaking, larger than all the infrastructure for roads and
railways, but what has to be done, has to be done.

The total solution lies in creating

1. The infrastructure
2. The manpower
3. Task sharing/Shifting

1. The Infrastructure

Fortuitously this is the only government that has for the first time in over 70 odd years taken healthcare seriously and created the ambitious Health Scheme Ayushman Bharat which has two components: The First Infrastructure to have scattered all over rural India 150,000 Primary Care Centre. It must be made mandatory these Primary Centres are not mere concrete shells, devoid of planning or equipment where the doctor is often absent, and if present is unable to deal with the situation as has been the norm for several Primary Centers so far.

To make this dream of infrastructure come true each Primary Centre needs professional, meticulous planning and construction, equipment to make it perform as a Mini-Hospital, and trained manpower allocation – Surgeons, anaesthetists, nurses, and support staff. The size and capacity of the primary centre will depend on the density of the surrounding population and could vary from 7 beds to 40 beds.

If we mean business every Centre must
– Be Accessible within timely reach – hence planning in the centre’s location
– Well managed, stocked, and equipped
– Staffed by trained, committed personnel.
– Ensure it is affordable for a rural family

Timely reach is important, an emergency that has to travel 100 kilometers to reach safe surgery has a 16 times greater mortality than one within 1-10 kilometers. Cost is a major factor for patient delay or refusal to seek help. not only the patient but the entire family becomes financially crippled and in debt indefinitely as a result of treatment.

The second component of the Ayushman Bharat is that it is the world’s largest Health Insurance Scheme, which covers the cost of treatment for millions of the underprivileged. This is a gigantic overwhelming humanitarian undertaking. However, most of the patients are taken to cities or the district hospitals adding greatly to the patient burden there. Further, this is a tremendous recurring annual expense, which could well be replaced by a sustainable permanent setup. Surgery must be self-sustainable and must be taken where it is required – in rural India.

2. Workforce

There is poor reliable data for the number of surgeons, gynaecologists, anaesthetists, and nurses in India. It is reported that India has 7 Surgeons per million population, the recommended number is almost 200. How do we increase the surgeon density to staff the 150,000 Primary Centres we plan to create?

Creating a new medical college may not be a solution India already has the largest number of Medical College in the World 595. The dearth of teaching staff and that it would take 10 years for a surgeon to emerge are deterrents.

India has scores of hospitals of 500-1000 beds in the private and public sector all over the country with a very high patient load. The National Board, after examining the Hospital could grant to these hospitals 2-5 DNB seats which over 10 years would yield 10-25 trained surgeons from each hospital.

3. Task sharing/Shifting

Task sharing is not new to India. I have seen task sharing in rural India since 1975, on numerous occasions MBBS Doctors doing excellent surgery. To me, performance is more important than a paper degree. That was almost half a century ago.

Today for safe competent task sharing there must be the proper selection, training to rise to a different level, mentorship, registration, adequate financial return, and respect. A large effort is required but all the effort for motivated safe task sharing is worthwhile for there is a large pool to draw from.

MBBS doctors who have done surgical residency could be drafted into the task-sharing force after additional training. AYUSH Surgeons who are recognized by the Health Ministry on par with allopath surgeons, could similarly with some apprenticeship be part of the force. Every surgeon in India counts. Surgeons from Teaching Hospital retire at 60. Many may be happy to come on board, also provide on the spot mentorship and training.

With the quality of life having improved so meaningfully in small towns and villages, young surgeons struggling in the cities with a dog-eat-dog environment may want to or could be induced, to move to a more peaceful and satisfying workplace. Every Surgeon in India counts.

It is futile to create a large surgical workforce if there is no proportionate increase in the number of anaesthetists, nurses – qualified or task sharing. This would require appropriate activity from the respective specialties. Creation of Primary Care Centres will be built over some time for 150000 to be functional, giving time to create more surgeons, anaesthetists, and nurses over the years as more
centres become functional.

India is not the first country to have these aspirations. Mexico, Mongolia and over 15 other MLIC have already started on this path and anticipate providing safe surgery for all by 2030 – 2032. If they can why not India? Why not other MLICs?

If at the primary centres the Bellwether conditions, i.e. cases of Caesarian, abdominal emergencies, compound fractures can be safely met, 80% of surgical care in India could be done at the peripheral level, reducing the heavy patient load in the city hospitals. At AIIMS Delhi the waiting period for surgery is 4-8 months. Unmet surgical care impacts the patient, the family, their income, and further, the National economy by 2%-3% of the GDP every year. Surgical care for all is not only a humanitarian necessity but will also be a financial windfall for the country.

This goal will require full, total committed Government action, together with an active and involved Private Sector, every Medical Association, dedicated doctors involved and concerned, and friends from abroad, many of them stakeholders for this Conference, for advice, help, support, to pool their efforts in this cause. Sincere efforts and the ultimate success will be by far the greatest triumph, the ultimate success story in the history of surgery, to ensure surgical care for all. This utopian dream can take years, a decade, way beyond my time, but when the fundamental right of surgical care, and all health care is met, India will be a fair, just, better country.

“Our doubts are traitors and make us lose the good we oft might win by fearing to attempt”
– W. Shakespeare

Success is not a destination. Success is a journey, and we have an exciting heartwarming journey ahead of us.

Dr. T.E. Udwadia
Prof Emeritus
Breach Candy Hospital Mumbai
Formerly GMC & JJ Hospital, Mumbai

Use of autologous platelet rich fibrin in minimally invasive treatment of perianal abscess

1st International Congress for Innovation in Global Surgery

Use of autologous platelet rich fibrin in minimally invasive treatment of perianal abscess

Anoop vasudevan pillai , Riju Ramachandran

Fistula in ano, once called “The Royal Disease” has been described from the time of Hippocrates. The earliest successful treatment described in literature is for King Louis XIV. This common ano-rectal disorder still continues to cause significant discomfort for patients. The traditional management of perianal abscess is a cruciate incision & drainage, resulting in morbidity. The wound takes months to heal with chronic pain, scarring and discomfort. Literature reports fistula formation in 35-50% following treatment of perianal abscess.

This is a case series of 5 patients (3males & 2females) who presented with perianal abscess. MRI done showed intersphincteric tract in 3 patients, horse shoe abscess in one and trans-sphincteric collection in one patient. Under anesthesia, a 3mm incision was placed at the region of maximum induration. Methylene blue+ hydrogen peroxide was injected into the cavity and internal opening was visualized. A 3mm fistuloscope was inserted into the cavity through the incision and the entire cavity was visualized upto the internal opening. All slough and unhealthy tissue was removed and the walls of the cavity fulgurated(Video). The internal opening was then closed using 2-0 vicryl in a “figure of 8” pattern. Horizontal centrifugation-Platelet rich fibrin (H-PRF) was placed into the treated cavity. Patients were discharged next day and followed up for 3 months postoperatively. All patients reported minimal pain for 2-3 days and complete cessation of discharge by 2nd week without progression to fistula.

Conventional treatment of acute perianal abscess is a large cruciate incision at the region of maximum fluctuation and breaking the septa within the abscess cavity. This may cause damage of the sensory nerves supplying the perianal region. Use of minimally invasive methods prevents this disruption in the anatomy of the region reducing morbidity and hastens healing. Escherichia Coli and skin commensals like Staphylococcus aureus are the most common isolates from a perianal abscess. H-PRF has tissue factors that can accelerate wound healing and also has an antimicrobial effect against E.Coli and staphylococcus.

Minimally Invasive Treatment of AnoRectal Abscess with H-PRF instillation helps in efficient, early, cosmetic and cost-effective healing of this painful condition.
A large section of the population in low resource or rural settings can be benefitted by this procedure with minimal modification to the operative technique.

Keywords: Anorectal abscess, VAAFT, Minimally invasive procedure, Incision & Drainage

Machine Learning based mortality prediction model for COVID-19 patients admitted in a tertiary care hospital, New Delhi.

1st International Congress for Innovation in Global Surgery

Machine Learning based mortality prediction model for COVID-19 patients admitted in a tertiary care hospital, New Delhi.

Sanjeev Khanth P E , Manukumar Shetty , Vandana Roy, Lalit Gupta


SARS corona virus 2 is found to be responsible for the COVID-19 pandemic. It caused severe acute respiratory illness with a high mortality rate. This deadly disease infected around 4 crore population in India and costs around 5.2 lakh deaths. This enveloped RNA virus is transmitted from the aerosols of infected patients. The virus attaches to the host with its spike protein to ACE2 receptors of lung epithelial cells and begins its replication. The symptoms can range from mild severity like sore throat, fever, and cough to severe category like pneumonia and ARDS which leads to increased mortality. There is a huge interindividual variation in response to the virus. It is often unpredictable to decide the course of the disease. Comorbid conditions like diabetes, hypertension, and major organ failures have been known to increase the severity of the disease. Therefore, the aim of this study was to apply an interpretative Artificial intelligence algorithm for identifying the main features which decide the course of the disease.


It is an observational study of hospitalized COVID-19 patients. 1181 RT-PCR confirmed COVID-19 patients (both alive and dead) data was used to predict the factors responsible for the course of the disease using a ML model. Twelve features were used to train [75%] and test [25%] the datasets using logistic regression and 2 machine learning methods [ XG Boost, Random Forest (RF)]. AI model interpretability was analyzed using a SHAP summary plot.


Among those patients analyzed using different AI models the Random Forest algorithms had higher sensitivity (83%) and accuracy (81%) on test datasets. Among the 12 features, AI interpretable SHAP summary plot showed age, kidney disease, heart disease, diabetes, male sex, and hypertension among the top rank features which have a high impact on the outcome of the disease (death).


We observed that AI interpretable model ranks the major factors that are contributing to the death of the patient and is able to predict the key ranking features with 83% sensitivity. Higher the age higher the risk of mortality. It also predicts that patients with heart disease, kidney disease, and diabetes are at higher risk for mortality. This model can be implemented in all healthcare facilities for risk stratification in COVID-19 patients. It helps in the proper management and taking necessary precautions beforehand.

Keywords: COVID-19, Artificial Intelligence

Perceived impact of trauma audit filters on trauma care in a tertiary care hospital: a qualitative analysis

1st International Congress for Innovation in Global Surgery

Perceived impact of trauma audit filters on trauma care in a tertiary care hospital: a qualitative analysis

Jyothis Greeshma Abraham , Anurag Mishra
Maulana Azad Medical College, New Delhi, India

Trauma, external injury in combination with the body’s response, is a major threat to global population. Trauma care is time sensitive, early identification of fatal injuries and conditions are very essential for survival and care of the person. Quality of trauma care remains a big concern in LMICs. Trauma has also been recognised by SDG 3 and targets to reduce trauma burden.

We at Maulana Azad Medical College (MAMC), New Delhi conducted a survey in a hybrid setup (in-person, phone call) with Trauma Audit Board (TAB) members associated with another ongoing Project on Trauma Filters at MAMC.

AIM: To know, the creation of TAB has been useful or burden in patient, hospital management or with Physicians etc.

Composition of TAB- Medical Director of the hospital, Heads of Emergency, Anaesthesia, Radiology, Orthopaedics, Surgery etc., and Investigators associated with the project.

Method of Survey:
A semi-quantitative questionnaire to record their feedback and impression via means using hybrid setup as per the clinician’s convenience, about TAB and their opinion about such audit board meetings, it’s impact on Trauma Care and other hospital-based problems.

Link to questionnaire:

Each clinician associated with project was 3.81 years. Only the MD of the hospital changed after his tenure of 2 years. Board was intact since its inception from 2017.

Clinicians noted a mean average of 7.27 on a scale of 1 to 10, after the implementation of TAB meetings.

To exemplify the scale, 2-3 popular responses as follows:
• Monitoring of Vitals like GCS, Respiratory rate, Blood pressure were noted which were earlier missed.
• Ultrasound machines were setup near patient bedside in Casualty.
• Trauma patients were managed in a more systematic way without wastage of time in inter departmental referrals.
• More responsible, more vigilant and aware as data were recorded and cases were studied in audit meetings

Other than trauma care an impact was seen in overall hospital functioning with inter-departmental co-ordination, more productivity in patient management were seen even during Covid waves with easy referrals with just an update on WhatsApp group which were initially created for the board meetings.
Many Clinicians even realised an impact on themselves with change in behavioural, attitudinal and inter-personnel skills, with such meetings they could learn from cases and functioning of other departments which would otherwise be missed. On a scale ranging from 1 to 10 when asked about how much of a burden it was attending TAB meetings on an average only 2.36% of a burden on a monthly basis which is quite negligible, as more clinicians looked upon learning more things for better patient care. Recommendation to other Institutes about such TAB meetings was a definite Yes.

Findings suggest a significant difference in healthcare management in the hospital.
Results and opinions suggest such meetings should be more periodically conducted and should be recognised as part of Hospital standardization.

Keywords: Trauma, Audits, Trauma Audit Board, Positive and negative impact

An innovative surgical method to operate the zygomatico-maxillary-orbital complex in the absence of intraoperative computer tomography or intraoperative navigation using novel zygoma analysis and virtual surgical planning software

1st International Congress for Innovation in Global Surgery

An innovative surgical method to operate the zygomatico-maxillary-orbital complex in the absence of intraoperative computer tomography or intraoperative navigation using novel zygoma analysis and virtual surgical planning software

Prem K Rathod, Rahul Yadav , Ongkila Bhutia, Ajoy Roychoudhury, Krushna Bhatt
Maulana Azad Medical College, New Delhi, India

Post-traumatic residual deformities of the Zygomaticomaxillary orbital complex (ZMOC) are challenging to operate on and may require intraoperative CT or navigation. Two major reasons for this are 1) Such devices costs crores of rupees, and 2) there is no method to quantify the amount of asymmetry of ZMOC. The purpose is to evaluate the surgical outcomes in the absence of intraoperative CT or Navigation using innovative zygoma analysis software planning and novel surgical protocol in operating these patients.

In this prospective study, a Zygoma analysis software planning was designed. Unilateral post-traumatic residual deformity of ZMOC (>10 weeks) was included. The uninjured side of the face was used to mirror, measure, and formulate the surgical plan after comparison with the injured side using this virtual surgical software planning. The primary objective was the symmetry and stability of ZMOC. Secondary outcome variables were changes in orbital volume, diplopia, ocular motility, mouth opening, and patient satisfaction. P < .05 was considered statistically significant. Measurements were assessed on affected and unaffected sides preoperatively, postoperatively, and six months postoperatively (Figure 1 shows measurements of zygoma analysis and virtual surgical planning). Paired t-test was used to compare the continuous variables. The continuous variable changes with time were evaluated using repeated measure ANOVA, followed by multiple comparisons using the Bonferroni test. The McNemar test assessed the changes within the categorical variable. P <.05 was considered statistically significant.

Thirteen patients were included (mean age = 28.38 ± 9.54 years; male:female = 5.5:1; left:right = 7:5). The mean duration of the residual deformity was 6.66±6.43 months. There was an improvement in the symmetry, and all parameters remained stable when measured at six months postoperatively. Patients reported a median satisfaction score of 4 out of 5. There was a significant improvement in orbital volume(P = .001) and mouth opening(P = .014).

The zygoma analysis virtual surgical planning software protocol results are comparable to those with intraoperative CT and navigation, thus proving a cost-effective innovation. These results proved to be stable over at least a 6-month follow-up period. Measuring the asymmetry of ZMOC and formulating a surgical plan becomes easy with zygoma analysis. This method is a solution in decision-making for treating bilateral residual deformities of the midface, aesthetic malar augmentation, aesthetic malar reduction cases, bilateral fractures of the zygomatico-maxillary-orbital complex, etc. It is now possible to operate and provide predictable outcomes in these cases when intraoperative CT or intraoperative navigation facilities may not be available.

Keywords: Zygomaticomaxillary complex, ZMC, orbital fractures, residual deformities, zygoma analysis, virtual surgical planning, symmetry, trauma, fracture

Carica papaya fruit in the management of chronic non healing ulcer wounds

1st International Congress for Innovation in Global Surgery

Carica papaya fruit in the management of chronic non healing ulcer wounds

Divyata A Vasa , Tapan A Shah, Mukesh S Suvera, Jaimin D Shah, Yagnik N Katara
Maulana Azad Medical College, New Delhi, India

The concept of using papaya as a debriding agent came from the use of papaya latex as a debriding agent in Ayurvedic practice. Carica papaya contains proteolytic enzymes namely papain and chymopapain in the fruit, latex, leaves, stems, and roots.It contains antioxidants like caffeic acid, myricetin, alphatocopherol and kempferol. Its proteolytic action is marked in acid, alkaline, and neutral solutions and has a digestive power at a wide range of temperatures and pH. This study aims to deduce the role of Carica papaya pulp in the management of chronic non healing ulcer wounds. Method: The study was, open-labeled interventional study carried out for 18 months in the inpatient department of General Surgery at L.G. Hospital. All patients with chronic non-healing ulcer wounds including diabetic foot ulcers, who consented to participate in the study were included. Patients with pre-existing cardiac conditions or immunocompromised states, patients younger than 15years of age, mentally challenged patients and severely anemic (Hb<6gm/dl) patients were excluded.
Detailed history of the enrolled patients was taken and details like age, history of allergies and atopic nature, and any significant past surgical and medical history were noted. Local examination of the wound was done, the presence of slough, type of discharge, and nature of granulation tissue at the base of the wound.
Patients received papaya dressing – placing autoclaved dressing gauze containing well-cleaned, peeled, and quarter sliced, steam disinfected raw papaya on the wound bed which remained in situ for 24 hours. The dressing was removed after 24hours and the condition of the wound was noted. The dressing was continued in both groups till the presence of healthy granulation tissue; serous non–foul smelling discharge; and complete absence of slough at the center of the wound. Number of days for which dressing was required before achieving the end point was noted. Results
The study included 28 patients: 26 males, 2 females from ages 18 to 65 years (mean age 51 years).
The average day on which health granulation appeared was 3rd day (mean 2.8 SD 0.93).
The average end point of therapy was 7th day (mean 7.6, SD 1.7). Mean hemoglobin at the start and end of therapy was 11.10g/dl (SD 2.14) and 10.7g/dl (SD 1.97) respectively, showing relatively less blood loss.
10 (35.7%) of the patients were diabetics.
Patients reacted to the visual analog scale (with 1 being mild bearable and 10 being the severe unbearable pain experienced) with moderate bearable pain (mean 5 SD 1.4).Conclusion:In India, with the average cost of chronic ulcer wound care being USD1956/Patient and per capita income being USD 2191/Person, the financial burden of management of chronic non-healing ulcer wounds is overwhelming. Current management methods include betadine with H2O2, silver-based dressing materials, surgical debridement, enzyme extracts, etc. Dressing with Carica papaya significantly reduces the overall cost burden owing to its easy availability, reduced hospital stay and visits. The overall patient compliance is better owing to the reduced cost of treatment and reduced/no need for surgical debridement following papaya dressing.

Keywords: Carica papaya, chronic, granulation, slough, pain, ulcer

The Buddy System: An initiative to slow down the antibiotic misuse

1st International Congress for Innovation in Global Surgery

The Buddy System: An initiative to slow down the antibiotic misuse

Taranjot Kaur , Ishaan Wazir, Alia Naaz
Maulana Azad Medical College, New Delhi, India

The dearth of new antibiotics and rising antimicrobial resistance (AMR) is a global challenge. With almost 700,000 people losing the battle to AMR every year and another 10 million projected to die from it by 2050, AMR is killing more people than cancer and road traffic accidents combined, in India.

Easy availability of drugs, prevailing misinformation, and the absence of proper guidelines for public use have resulted in irrational antibiotic consumption. Our innovation – the “Buddy System” is in no way an alternative to these antibiotics, but, it does have the capability to slow down this process and buy us sufficient time to make amends.

AMR has multifactorial causation, however, but our focus, here, is on the patient aspect (mainly self-diagnosis and treatment). With a population of 1.38 billion, it is extremely tough to impose the regulations, so our best bet is to increase awareness. We aim to educate the general public about the rising trends of AMR and judicial use of antibiotics, enabling them to make prudent and informed choices, resulting in lesser antibiotic abuse and a flattened curve of AMR.

The Buddy System uses a hybrid of the orthodox concept of PHONE TREES and modern tactics. Our vision is to form a network, wherein interested medical students (Buddy officers) will be allotted one school each, where they will make a team of students and educate them. These school students will further train their acquaintances, relatives, and the general public, expanding our reach exponentially.

We have planned our Buddy System from scratch and have formulated a detailed plan that addresses the financial, structural, and therapeutic hurdles, including some major challenges like the lack of consistency, standardisation of data, large population size, monitoring, and feedback.

Our intervention is unique because the person at the top of this hierarchy will be a trained medical officer and hence, the data will be evidence-backed and medically sound. Further, we plan to use our biggest challenge, i.e., huge population, as our mighty asset to expand our reach. All we need is a roadmap to create a working model by reallocating and recruiting the general public in this machinery to create this self-sustaining, community-based model of preventive health care. The sole use of trained manpower makes this project very cost-sufficient and feasible.

The most critical part, however, will be to find the source of continuous motivation for all, which we know would not be easy. We are betting on our convincing skills to try and rope in the local authorities and the educational institutes. We also hope that once we will set up a basic working model, it will be easier to get good backup from our government as well as the international agencies.

Millions of dollars are being invested globally to develop antibiotics; however, our intervention provides a much cheaper and time-effective alternative. Feeding the public correct and unadulterated information and making them realise how their everyday choices will have a much wider impact than they think, will help us win the battle against AMR.

Keywords: Antibiotic Abuse, Antimicrobial Resistance, Public Health

SOCH – India (Students’ Orbit for Collaborative Healthcare – India)

1st International Congress for Innovation in Global Surgery

SOCH – India (Students’ Orbit for Collaborative Healthcare – India)

Students’ Orbit for Collaborative Healthcare – India
Maulana Azad Medical College, New Delhi, India

A study reported that 25 Indian medical institutions published more than 100 articles in a year, accounting for 40.3% of the country’s total research output between 2005 and 2014, while 332 medical colleges in the country had no publications. There is a need to encourage medical students to learn about evidence-based medicine. It helps achieve the Triple Aim’s objectives of improved quality, improved patient satisfaction, and reduced costs by influencing treatment, healthcare management and policies. However, there currently exist several lacunae in the Indian medical curriculum to involve understandings of evidence-based medicine and research in its formal training programmes. Local, regional & global collaborations can help promote research, leadership, and capacity building between medical students & health professionals. SOCH – India (Students’ Orbit for Collaborative Healthcare – India) derived from the Hindi word ‘SOCH’ which means ‘a thought / an idea’ is one of India’s first medical student-led national research collaborative networks (SCRNs). It aims to provide Indian medical students with unique applied academic training experiences, as observed in UK trainee-led collaborative study models like STARSurg.

The structure of the collaborative network involves:
1. Senior mentor guidance: Higher degrees of credibility, scientific validity, efficient methodology, and impact are made possible by faculty representatives serving as the collaborative network’s guides.
2. Core Support Team: Student members of the collaborative serve as the study’s coordinators, advancing the collaborative’s goals and objectives. They are grouped into a steering committee, operations committee, research capacity building committee, writing group, statistics group and data validators.
3. Regional, State and Local Leads: Students from different regions of the country collaborate to provide data for improved generalisability.
4. Authorship: It is inclusive and stated before participation in the study. Under a single collaborative network, all members can pose as citable authors.

There are currently 606 medical colleges offering 92115 seats for medical aspirants, according to the National Medical Commission (NMC) India, the regulating body in charge of medical education and professionals. A significant proportion of this future healthcare workforce is yet to participate in research. The most common barriers medical students face to engaging in research during all years of study include lack of formal training, inadequate knowledge, time commitments, a lack of opportunities, and the absence of research culture at their universities. SCRNs can help overcome these obstacles and promote research among medical students. Furthermore, the quality and quantity of research can be potentially increased with such collaborative research models. Due to regional diversity, collaborative networks allow a multi-centric approach study with high numbers of patients in a rapid time frame. They strengthen the principles of repeatability, validity, consistency, and timely reporting of study results. SCRNs have benefits by making research more accessible, increasing time efficiency with collective training, and cultivating research into clinical practices.

As SOCH-India expands opportunities for medical students across India, a low- and middle-income country with limited resources, it can potentiate an increase in the country’s research output. It paves the long-term path forward by promoting the use of evidence-based medicine in clinical practice, therefore, enhancing the healthcare system.

Keywords: Research, Capacity Building, Medical Education, India, collaborative

Need of an Autopsy Kit in resource limited settings

1st International Congress for Innovation in Global Surgery

Need of an Autopsy Kit in resource limited settings

Mrinal Patnaik
Maulana Azad Medical College, New Delhi, India

Introduction: Autopsy is a primary source of anatomical and pathological research in human body. The instruments required in autopsy depend upon the degree of detail required in dissection and the method of autopsy used. Availability of surgical instruments, in adequate quantity or variety, their logistics to the site of autopsy is a challenge.
Methodology: The question was what decisions are made regarding supplies and sterile instruments in autopsies. Systematic analysis of literature was done where research papers dedicated to Operating room inventory, field necropsy procedures and surgical kits for different parts of human body and manuals and/or guidelines for autopsies were reviewed.
Results: The number, type and cost of instruments required in autopsy depend upon the method of dissection and type of autopsy performed, viz. Minimally Invasive Autopsy (MIA), Partial Autopsy, Complete Autopsy, Complete Diagnostic Autopsy (CDA) or Virtual autopsy, decided on technical grounds, feasibility, consent and the mandate of the authority requesting the autopsy.
Discussion: A comprehensive cost effective autopsy kit with necessary inventory of commonly used instruments could be promptly made available upon requirement with essential equipments and additional instruments as needed for special circumstances to satisfy a balanced outcome.

Keywords: Autopsy, Instruments, Postmortem, Kit

Empowering The Rural Surgeons, The Way Forward For Meeting The Surgical Needs Of Rural Areas

doi: 10.52648/JoGS.1136
Empowering The Rural Surgeons, The Way Forward For Meeting The Surgical Needs Of Rural Areas
Gnanaraj Jesudian

India Education | General surgery | Urology

Keywords: Rural Surgery, Surgical Camps, Surgical Coverage

SUBMITTED: 29.06.2021 PEER REVIEWED IN: United Kingdom, India, Mexico ACCEPTED: 13.08.2021 PUBLISHED: 14.08.2021
Globally, 60% of the surgical procedures are carried out for 15% of the world population in developed countries. The Lancet commission on Global surgery estimates that a population of 100000 would ideally require 5000 surgical procedures every year. Although the national average is about 800 in most of the rural areas in India, in the North-eastern states it varies from 30 to 300. We look at the various models and options available for empowering the surgeons in the rural areas. Short Term Medical Missions have been used for a long time including those with structured programs. Pioneering long term medical missions are few and difficult to sustain. Empowering surgeons working in rural areas with modern surgical techniques is a sustainable solution with high impact. Empowering the rural surgeons with training in Gas Insufflation Less Laparoscopic Surgeries and Endoscopic Urology surgeries helped the surgical coverage in the target population of the 8 rural hospitals studied go up from 1287 per 100000 per year to 2880 the next year and 3739 the following year. It is a financially sustainable model that could be scaled up by funding travel of the trainers and equipment for the trainees.


Globally, 60% of the surgical procedures are carried out for 15% of the world population in developed countries. On the other hand, 34% of the poor who live in developing countries get only 3% of the world’s surgeries [1]. While the World Health Organization (WHO) recommends that there should be at least 20 surgeons per 100,000 populations, countries like Rwanda have only 0.4 surgeons per 100,000 populations [2]. The Lancet commission on Global surgery estimates that a population of 100000 would ideally require 5000 surgical procedures every year. Although the Indian national average is about 800 in most of the rural areas and in the North-eastern states it varies from 30 to 300 [3].

The problems related to providing the surgical care for rural patients are many [4-5]. It starts with not knowing how many of them need surgery [6]. Most of the problems are related to accessibility, availability, and affordability for the patients. For the surgeons, the major problems are the lack of equipment, training, and the qualified support staff. There also the legal problems like the Government regulations limiting the use of ultrasound in rural areas and transfusion of unbanked blood. The corporate hospitals try to prevent the rural areas from performing surgical procedures so that they have patients for surgery. They do this by advertisement and enticing the rural surgeons to move to urban areas. We look at the various models and options available for empowering the surgeons in the rural areas.


We looked at the various models of empowering the rural surgeons working in rural and remote areas. Some were from historic data from publications like the Short- and Long-Term Missions. The data from the hospitals where, the author organized the Surgical Camps both before and after the Surgical Camps were analyzed to assess the benefit of the intervention. The tool used for comparison was the rate of surgical coverage calculated by surgical procedures for every 100000 population in the target areas every year.


Caring for the sick has long been considered a hallmark of Christianity. Christian health care workers cite biblical references of the call to medical missions as an example of God’s unconditional love (Matthew 10:8; Luke 10:8-9, 25-34). Although Christians have been involved in medical missions throughout history, participation in short-term medical missions (STMMs) has grown dramatically in the past few years [7]. The most cost-effective, feasible, and replicable methods to implement the complex systems needed to provide surgery are still debated [8]. The short-term surgical missions can be structured in a way high quality sustainable care could be provided as shown by Operation Smile, Himalayan Cataract project, Team Hear and Partners in Health, etc. [8]. Common criticisms include unsafe practices, lack of consideration for cultural differences, and lack of coordination with the host country. But the positive impact of STMM teams in providing much needed services to resource- limited countries calls for continued efforts to sustain this ministry [9].


Pioneering work in remote areas often attract young surgeons and they can help take surgeries to remote rural areas [10]. There are several factors that discourage young doctors to work in remote and rural areas [11]. Figure 1 summarizes these factors [11]. Studies have also shown that although many doctors do go to rural areas for a variety of reasons many do not stay on in rural areas [12]. A study by the Public Health Foundation of India and the National Rural Health Mission of the Government of India in Chhattisgarh [13] found that practitioners’ initial decisions to join service in rural and remote areas were widely influenced by geographical affinities and familial associations. Once in service, the practitioners confronted complex adverse conditions and circumstances, including poor working and living arrangements, long estrangements from families, and threats to personal security. Once they left the rural areas for whatever reason hardly anyone came back. The reasons that were given were the following.

  1. Toiling in obscurity
  2. Constraints in working conditions.
  3. Erosion of Professional Skills
  4. Lack of good schools
  5. Lack of need specific training.

Figure 1:  shows the Motivating and demotivating factors

Another important reason that attracts surgeons to work in rural areas is training [14]. The Pan African Academy of Christian Surgeons [PAACS] offers rural based general surgery program that has a retention rate of over 50% in short term and 35% long term. Opportunities for learning and upgrading skills through contact with the parent missions abroad helped many of the surgeons stay on in rural areas working with the mission hospitals [15].


Empowering the rural hospital to do procedures that are new and not available at other places help in retaining surgeons in rural areas. The Burrows Memorial Christian Hospital in the year 2002 started the Diagnostic Camps – Surgical Camp model [16]. This helped the hospital increase the number of surgeries from 92 per year to 3685 a year [17]. Most of the diagnostic facilities available at the hospital was taken to the remote rural areas where the surgical diagnosis was made. The patients then came to the hospital for surgical treatment. There was no external funding and patients paid for the treatment.


The density of specialist surgeons, anaesthetists, and obstetricians (SAO number) per 100 000 population, correlates with specific health outcomes. The WHO recommends 20-40 SAO / 100,000 population. In India, the SAO number is 6.8 with the rural number being an abysmal 2/100,000 which is the same as sub-Saharan Africa [18].



Mentorship or teaching new skills by mentors who visit the rural surgeons to train them is wonderful way of empowering the rural surgeons. For example, while one of the authors trained at Christian Medical College [CMC], Vellore the college had not started Laparoscopic surgeries. Faculty from CMC Vellore stayed for two weeks with the author to train in laparoscopic surgeries. Similarly, overseas visiting surgeons can teach new skills that empower the rural surgeons [19]. This type of training is possible when the mentors know the trainees well and understand their capabilities. Empowering the rural surgeons was felt as a great need during the Karad Consensus meeting organized by Lancet commission on Global Surgery [20].

In this model the trainers’ salaries and often the travel was paid by the parent institutions, or the project and the trainees took care of the local hospitality of the trainers.

Figure 1: Motivating and demotivating factors
Table 1: Follow up of trainees.
8 3 Went back and started laparoscopic surgeries in their places Most of them had the equipment purchased by the mission earlier and two had gone overseas for training earlier
5 12 Regular laparoscopic surgeries at their places They needed the team to come there and were doing surgeries for a long time only during surgical camps
4 1 No laparoscopic surgeries Although they had the equipment did not start regular surgeries
6 1 Lost to follow up After the training did not keep in touch


From the year 2003 to 2013 the team from the organization SEESHA [21] organized 116 surgical camps at 29 different rural hospitals. During this period about 23 junior surgeons either accompanied the team or were at the local hospital to learn. The surgical camps were typically for 3 to 4 days at a place and most of the time was combined with another place [22].

The following table 1 gives the results of the training that they received and what they did after the training related to laparoscopic surgeries. It shows that half of them had training at only one surgical camp and this was not sufficient for them to continue laparoscopic surgeries thus highlighting the importance of regular Proctorship

The results also show that those who continued to do laparoscopic surgeries when they went back to their places or at the place where they received training needed a minimum of 3 such surgical camps and some required as many as 12 surgical camps for sufficient training.

Table 2 gives the list of Laparoscopic Surgeries carried out during these surgical camps [14]. Although the exact numbers are not available after doing a few themselves the Proctors helped the local surgeons do these surgeries.

Table 2: Number of Laparoscopic Surgeries carried out during Surgical Camps

Table 3 shows the number of surgeries performed in some of these places during the next few years. These include only the major surgical procedures but just with these calculations show that the surgical coverage increased from 235 to 628 per 40000 population which translates roughly to an improvement of one and a half times the surgical coverage of the target population [from 600 per 100000 to 1500 per 100000 populations]


The University of Leeds through their NIHR – GHRG project [23] started the Project GILLS for the rural surgeons primarily in Northeast India. The project developed a formal training program in Gas Insufflation Less Laparoscopic Surgeries [GILLS] and organized the Target training program [24].

During the year 2019 the Project GILLS worked with rural surgeons from Tukrajhar in Assam near Bhutan border, Medzhiphema in Nagaland, Aizawl in Mizoram, Biru in Jharkhand, Satoli in Uttarakhand, Ambilikai, ICC Hospital, Sitilingi and Gudalur in Tamil Nadu and Bhalukpong in Arunachal Pradesh.

Table 4 shows the number of days spent at the various hospitals training and empowering the rural surgeons.

The travel cost to the project during the year 2019 was INR 2017409 [21696 Pounds or 1808 Pounds a month]. The project team stays in South India and the travel was to Northeast India (Assam, Mizoram, Nagaland, Arunachal Prades), Uttarakhand, Jharkhand and South India covering about 8000 to 10000 kilometres a month. In addition, the cost covers one training program for the 6 trainees and the cost of the faculty or trainers for the contact training program and two formal Proctor –ship programs and few other visits of the faculty to the rural hospitals.

The cost works out to about INR 2756 (30 Pounds) per surgery carried out during the surgical camp.

The approximate target population served by these hospitals derived from the last census data is as follows [Table 5]

Many of these places before the rural surgeons started the work there had no surgical work going on at the hospitals. The examples are the Crofts Memorial Hospital, the Government CHC Medzhiphema and Jalukie and Aarohi. Some places like the Family Health Clinic and Tribal Health Initiative had few emergency surgeries like LSCS going on but not on a regular basis. Others like SBMC and Bethesda Hospital had less than 50 surgical procedures a year few years ago. All the rural hospitals listed started training with the project team before 2019 except Shanthi Bhavan Medical Center that started working with the team only during the latter half.

During the year 2019 a total of 732 major surgical procedures were carried out at the surgical camps. This includes 97 Gas Insufflation Less Laparoscopic Surgeries. There were 277 surgeries for urinary tract stones. The local surgeons learnt Gas Insufflation Less Laparoscopic Surgeries and Urology surgeries. The other surgeries were for patients whom they collected for surgical camps. The cost of these surgical procedures if carried out elsewhere would start from INR 60000 [645 Pounds] to the patients and often are much higher. If the costs of travel of the patient and relatives to the city for surgical procedures this cost could be well over 1500 Pounds per surgical procedure. The cost to the project including the salaries works out to about 60 pounds per surgical procedure carried out.

Table 6 shows the Surgical procedures carried out during the Surgical Camps

The total number of surgeries carried out at some of these places is given below in Table 7. The total numbers at these places in the calendar year 2018 and 219 are given and these include the surgeries carried out at the Surgical Camps.

The surgical camps alone added 317 surgical procedures per 100000 populations a year for the immediate target areas of the population. The immediate target population for the rural hospitals where most of the surgical procedures were carried out was 82180 and the number of surgical procedures there was 697. Hence for these hospitals alone if the contribution of the surgical camps were calculated it is 848 per 100000 populations a year.

In 2019 the Surgical Coverage in the immediate target population of the rural areas where these empowered rural surgeons were working was 3739 per 1000000 populations. This figure was 2880. for the year 2018 and if the trend continues in two or three years the Lancet recommended figure of 5000 per 100000 populations a year could be achieved in these areas.

Another thing to note is that the patients come from the extended target area for the surgical procedures and hence the actual coverage at the local target population would be less than the estimate indicates.

Table 2: List of Laparoscopic Surgeries during Surgical Camps
Cholecystectomies 17
Single Incision appendicectomies 12
Appendicectomies (multi – port) 5
Palamo Surgery 4
Duodenal ulcer perforation closure 1
Hernioplasty 1
Adhesiolysis 1
Single Incision Surgery for Infertility 52
Single Incision Ovarian Cystectomy 39
Ovarian Cystectomy (multi-port) 22
Single Incision LAVH 12
Single Incision Myomectomy 4
Myomectomy (multi-port) 3
Tubal recanalization 3
Tubal Ligation 3
Table 3: Major surgeries in some remote hospitals
Jalukie Nagaland (11) 74 89 216 1087 (8706)
Lunglei Mizoaram (9) 23 42 212 6808 (15000)
Sitilingi, Tamil Nadu 92 96 148 1474 (8500)
Bhalukpong, Arunachap 3 8 52 5042(8500
Table 4: Number of days at Surgical Camps
Aarohi, Satoli in Uttarakhand 7
Ashiwini Adivasi Hospital Gudalur, Tamil Nadu 4
Bethesda Hospital, Aizawl, Mizoram 12
Christian Fellowship Hospital, Ambilikai, Tamil Nadu 2
Crofts Memorial Hospital, Tukrajhar, Assam 19
Family Health Clinic, Dimapur, Nagaland 10
ICC Hospital, Coimbatore, Tamil Nadu 7
Medzhiphema Government CHC, Nagaland 10
Shanthi Bhavan Medical Center, Biru, Jharkhand 42
Tribal Health Initiative, Sitilingi, Tamil Nadu 4
Others 11
Table 5: Table 5: Approximate target population
Aarohi, Satoli in Uttarakhand 8120 30000
Ashiwini Adivasi Hospital Gudalur, Tamil Nadu 12100 150000
Bethesda Hospital, Aizawl, Mizoram 12000 250000
Christian Fellowship Hospital, Ambilikai, Tamil Nadu 36610 300000
Crofts Memorial Hospital, Tukrajhar, Assam 5250 500000
Family Health Clinic, Dimapur, Nagaland 15000 130000
ICC Hospital, Coimbatore, Tamil Nadu 70000 200000
Medzhiphema Government CHC, Nagaland 12170 70000
Shanthi Bhavan Medical Center, Biru, Jharkhand 44640 600000
Tribal Health Initiative, Sitilingi, Tamil Nadu 14740 78000
TOTAL 230630 2308000

The impact of the project could be summarized as follows.


The cost to the Project per surgical procedure carried out is about INR 5500 or 60 Pounds (including staff salaries, training programs, etc.) and to the patient about INR 9500 paid at the local facility. The cost saving per patient if these were carried out elsewhere would be about INR 120000 or about 1290 pounds per surgical procedure carried out.

In other words, the impact of the project was a saving of about 944280 Pounds or a saving of about 87.8 million rupees for the patients in 2019.


Few years ago, in the project area the Surgical Coverage would have been less than 30 per 100000 populations per year [as surveyed in 2017 from the Government data]. The presence of rural surgeons at these facilities improved the surgical coverage significantly. Although the exact figures are not available from the registers the approximate figures indicate surgical care coverage of 1287 per 100000 populations a year.

This increased to 2880 per 100000 populations a year when the rural surgeons started learning new procedures during the surgical camps and advanced surgical procedures were available during the surgical camps

In the year 2019 with the rural surgeons being empowered to do the new surgical procedures that they had learnt during the surgical camps the coverage increased to 3739 per 100000 populations a year.


During the project period that started in 2018 more rural surgeons started training with the model of onsite training with Surgical Camps. However, at one of the places it was not feasible to continue the Surgical Camps and the rural surgeons stopped the surgical camps and is considering moving out of the rural area. Two of the current rural surgeons had seriously considered leaving the place where they are working now. One of the significant considerations for them to stay on was the empowerment through the training.


Empowering Rural Surgeons is a cost – effective sustainable long-term solution for improving the surgical care in rural areas. Scaling up of the training could be enhanced by funding the salaries and travel of the Trainers for these Proctorship programs.

Table 6: Surgical procedures carried out during the Surgical Camps
Gas Insufflation Less Laparoscopic Cholecystectomies 24
Single Incision GILLS appendicectomies 12
GILLS Hernioplasty 6
Single Incision GILLS LAVH 10
Single Incision GILLS Infertility surgeries 28
Single Incision GILLS Ovarian cystectomies 12
Single Incision GILLS Myomectomies 2
Other GILLS surgeries 3
Ureterorenoscopy for renal and ureteric stones 259
Urodynamic studies 103
Cystolitholapaxy 18
Endoscopic Internal Urethrotomy 43
Transurethral vaporization of Prostate 48
Transurethral vaporization of bladder tumours 17
Other endoscopic Urology procedures 18
Renal and adrenal surgery 12
Reconstructive surgery 8
Open liver and GB surgery 7
Open gynecological surgeries 13
Open General surgeries 18
Orthopedic surgeries 7
Pediatric surgeries 12
Oncology surgeries 9
Others and minor surgeries 43
Table 7: Number of Surgeries carried out in 2018 and 2019
Aarohi, Satoli in Uttarakhand 8 37 61
Ashiwini Adivasi Hospital Gudalur, Tamil Nadu 320 400 448
Bethesda Hospital, Aizawl, Mizoram 50 147 300
Crofts Memorial Hospital, Tukrajhar, Assam 120 218 374
Family Health Clinic, Dimapur, Nagaland 40 138 165
Medzhiphema Government CHC, Nagaland 20 82 104
Shanthi Bhavan Medical Center, Biru, Jharkhand 300 625 814
Tribal Health Initiative, Sitilingi, Tamil Nadu 200 720 807
TOTAL 1058 2367 3073

1. Gnanaraj J. Working with Limited Resources in India: Take-Home Messages from the 2015 Bethune Round Table. MD Current India Vol. 4 June 2015. (accessed Aug 13, 2021)
2. World Health Organisation. World Health Statistics 2011. (accessed Aug 13, 2021)
3. Gnanaraj J. Diagnostic and Surgical camps for taking MIS to remote areas: A report about Bhalukpong in Arunachal Pradesh. MD Current India Vol. 7 June 2018. (accessed Aug 13, 2021)
4. Oluyombo A. Rising to the challenge of rural surgery. Bull World Health Organ 2010;88:331–332. (accessed Aug 13, 2021)
5. Atiyeh BS, Gunn SW, Hayek SN. Provision of essential surgery in remote and rural areas of developed as well as low and middle income countries. Int J Surg. 2010;8(8):581-5 [crossref]
6. Gnanaraj J. Diagnostic and surgical camps: Cost-effective way to address surgical needs of the poor and marginalized. MD Current India Vol 3. Jan 2014. (accessed Aug 13, 2021)
7. Grundmann GH . Mission and Healing in Historical perspective. International Bulletin of Missionary research. 32 (4), 185-188, 2008 [crossref]
8. Mody G, Swain J. Short term Surgical Mission: A vehicle for sustainable Surgical Care delivery. PLOS Guest Blogs. (accessed Aug 13, 2021)
9. Janice Hawkins. Potential Pit falls of Short - Term Medical Missions. Journal of Christian Nursing October / December 2013. (accessed Aug 13, 2021)
10. Gnanaraj J, Gnanaraj L, Shah VK. How to bring surgery to remote areas. Trop Doct 1997 Jul: 27 (3) : 163 – 5
11. Goel S, Angeli F, Dhirar N et al. Factors affecting medical students’ interests in working in rural areas in North India—A qualitative inquiry. PLOS ONE 2019;14(1):e0210251. pmid:30629641 [crossref]
12. Ghosh K. Why we don’t get doctors for rural medical service in India?. Natl Med J India 2018;31:44-6 [crossref]
13. Sheikh K, Rajkumari B, Bhattacharya et al. Why Some Doctors Serve in Rural Areas: A Qualitative Assessment from Chhattisgarh State April 2010. (accessed Aug 13, 2021)
14. Van Essen, C., Steffes, B.C., Thelander, K. et al. Increasing and Retaining African Surgeons Working in Rural Hospitals: An Analysis of PAACS Surgeons with Twenty-Year Program Follow-Up. World J Surg 2019 43, 75–86 [crossref]
15. Gnanaraj J, Michael Rhodes. Surgical work in Medial Missions. A study in remote areas of India. Christian Journal for Global Health. 1(2): 42-47. Nov 2014
16. J. Gnanaraj, Lau Xe Xiang Jason, Hanah Khiangte. High quality surgical care at low cost: The Diagnostic camp model of Burrows Memorial Christian Hospital. Indian Journal of Surgery Vol. 69, No.6, December 2007 p 243-247 [crossref]
17. Gnanaraj J. Marketing rural hospitals. CHRISMED Journal of Health and Research 2014: 1 p123-7 [crossref]
18. Meara J , Leather AJM, Lagander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet Commisions.| Vol 386, Issue 9993, p569-624 [crossref]
19. Gnanaraj J. Working holidays for overseas doctors: Host perspective in mission hospitals in rural India. Christian Journal for global health 2 (1), 35-42, May 2015
20. Till B, Saluja S, Raykar N et al. Surgical care systems strengthening: developing national surgical, obstetric and anaesthesia plans India. World Health Organization. ISBN 978-92-4-151224-4 p36 to 41
21. The Samiti for Education, Environment, Social and Health Action (SEESHA). (accessed Aug 13, 2021)
22. Gnanaraj J, Awojobi A. Learning Skills During Surgical Camps. MD Current India. (accessed Aug 13, 2021)
23. Global Health Research Group Surgical Technologies. (accessed Aug 13, 2021)
24. TARGET Project; Global Health Research Group Surgical Technologies. (accessed Aug 13, 2021)
The Journal of Global Surgery (ONE) is proud to transparently publish its financial model to determine the ethical publishing cost required to publish one peer reviewed article on the platform. This figure is determined by two principle calculations: the fixed running costs of the platform per article (for example annual web server fees, DOI registration), and the indivudalised stipend payments that each journal distributes to its volunteer staff to administrate, edit and review manuscripts. Each journal may set its own stipend value to the editors, peer reviewers and administrators that support the journal’s activities. Ultimately, the final article price tag will be known as the community article processing fee (CAPC). Once the article is officially published, the CAPC price tag can be paid in full by anyone (for example the authors, an institution, a philanthropist), or the article fee can be community crowd funded, where any individual can contribute to the CAPC to reduce the price tag for everyone else. Anyone contributing as little as $0.10 will have instant early access to the article, ensuring that even if the article remains locked, anyone in the world will have the opportunity for instant, affordable access to the article. And of course, once the CAPC has been paid in full, the entire community will have open access to the article with no further costs.










Description Cost ($)
Stipend made to peer reviewer for one peer review
Note: This is the amount in dollars paid to one peer reviewer, irrespective of whether article is accepted or rejected. *Assumption is that one article will have two independent peer reviews
Stipend made to editor per article undergoing active peer review
Note: This is the amount in dollars paid to the editor, irrespective of whether article is accepted or rejected.
Stipend made for administration and type setting per accepted article
Using our platform, the automated typesetting process is extremely efficient with instant publication options
Bitcoin Cash payment given to authors to allow them instant access to their own article. 2
Final journal specific running costs based on manuscript acceptance rate of 70%*
*based on estimation

Figures last updated: July 27, 2021 at 7:10 pm

Article creation cost: $76

Community payments to date: $76.00

Remaining payments for open access: $0.00

The following payments have been made to help pay for this article:

User Amount Payment method Date
Anonymous $0.10 Bitcoin Cash August 14, 2021 at 2:58 pm
Deyan Dimitrov $1.00 Bitcoin Cash August 14, 2021 at 5:11 pm
Anonymous $0.30 Bitcoin Cash August 14, 2021 at 5:27 pm
cesarmd3 $9.00 Bitcoin Cash August 14, 2021 at 5:50 pm
Anonymous $0.10 Bitcoin Cash August 14, 2021 at 6:42 pm
Anonymous $1.00 Bitcoin Cash August 14, 2021 at 7:33 pm
Anonymous $1.00 Bitcoin Cash August 14, 2021 at 7:57 pm
Jay $1.00 Bitcoin Cash August 14, 2021 at 7:58 pm
jlmoriart $20.00 Bitcoin Cash August 14, 2021 at 8:39 pm
Anonymous $0.10 Bitcoin Cash August 14, 2021 at 8:41 pm
Bitcoin Cash Love $0.50 Bitcoin Cash August 14, 2021 at 9:43 pm
Anonymous $0.10 Bitcoin Cash August 14, 2021 at 10:02 pm
Anonymous $20.00 Bitcoin Cash August 14, 2021 at 10:43 pm
Anonymous $21.80 Bitcoin Cash August 15, 2021 at 12:00 am
Number of abstract only views: 116 Number of full article views: 2154 Number of PDF views: 226