Inaugural Speech: Surgery in the face of low resources

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