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Presidential Address
Delivered at Xth, National Conference of the Association of Rural
Surgeons of India at VAPI, Gujarat, November, 2002 Sitanath
De President ARSI
Banshree Clinic Jhargram WB |
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It is indeed an honour and a
privilage to address you as President of the Association of Rural
Surgeons of India, at this, 10th National conference of our organization.
A.R.S.I. aims to improve rural surgery and, as a consequence, the
surgical care in rural India. It is therefore very appropriate that
we find ourselves assembled here at Vapi, in the heartland of Bapuji's
Gujarat. Perhaps our discussions and exchange of surgical ideas
may also contribute in some way, however, modestly, to Bapuji's
dream for the upliftment of Rural India.
While all of us are aware of the need to improve the quality, and
quantity, of surgical care delivered to the 70% of the population
living in the rural area, who are frequently denied even the most
basic amenities of life. Do we truly understand the enormity of
the task, we in our association are attempting? I am thinking about,
the city surgeons, the super specialists, taking magnificent strides
in technology to bring India to the forefront of modern surgery.
We admire you and are justly proud of your achievements. We welcome
those of you who have made the efforts to come and join our deliberations
today. But I ask you all, are you truly, aware of nature of the
"disease" we are trying to treat ? I mean, of course the
disease is poverty. Poverty is persistent and wide spread that we
cannot even dream of treating the patient with the barrage of sophisticated
'hi-tech' procedures that modern surgery has to offer. Let me illustrate
my point. In my own area of south West Bengal, the local population
is made up largely of agricultural workers, on daily wages. According
to the 1991 Census, the local per-capita income was found to be
Rs. 325 per month. The figures from the 2001 Census are not yet
available but have been estimated at not more than Rs. 1000 per
month. This amount is expected to look after a family of at least
four dependents. In these circumstances, I feel ashamed to ask for
even the simplest diagnostic test. Should I leave these patients
to the mercy of the local "quacks"? We in the A.R.S.I.
are determined to do our utmost to bring effective, economical surgical
care within the reach of rural India. But my friends, so far we
have only managed to grasp the nature of the diseases. In our efforts
to remedy the disease we have done no more than to make the first
skin incision ! In order to effect a cure it is necessary to make
a deep incision and eradicate the cause of the disease. The question
remains how shall we make that deep incision?
Until recently, there was a fairly reasonable system of delivery
of Rural Surgical care. 60% of all surgical needs were met by the
private sector, and the remaining 40% by the National/State Surgical
Health Services.
This system is on the verge of collapse. The state health services
have been compelled to charge the under privilaged section of society,
in order to raise revenue to pay back the huge loan they have taken
from the World Bank. Those below the poverty line are supposed to
be exempted from health charges, on the production of 'a Certificate
of Poverty". However, since such certificates are obtainable
from the nearest footpath, this attempt to gather revenue has merely
opened the floodgate to wide-spread. The result is that those who
had access to free medical care from the State Health Service are
now forced to pay for the treatment they receive.
The private sector, providing 60% of all surgical needs in the rural
area, is also under pressure. Those of us who have battled for years
to establish a small surgical clinic, where it is really needed,
in the rural area, are painfully aware of the enormous difficulties
involved. The physical struggle to create a modest building where
none of the basic amenities of water, power and transport are available,
the professional and social isolation and the pressing problem of
providing adequate education for his children are well known. Above
all, the lack of financial security for the surgeon and the extreme
poverty of his patients makes even the thought of setting up a surgical
clinic in the rural area, a daunting project. It is no wonder then
that the young surgeon of today quickly abandons any idealistic
dream of serving the rural poor and soon succumbs to the blandishments
of modern "commercial" surgery and the sophistication
and security of city life.
But my friends are we to abandon the patient on the operating table
itself ? He is still moribundly sick and any delay in treatment
could be fatal! Such severe disease requires drastic measures and
today I would like to prescribe, and strongly advocate, two lines
of urgently required treatment.
As a first line of action I would like to see a complete review
and adjustment of the Consumer Protection Act and the Clinical Establishment
Act as they stand in relation to small surgical clinics in the rural
area. On the face of it, the Consumer Protection Act, which equates
medical care service with industry, is a progressive move intended
to give people their rights- urban and rural medical facilities
should be equally available to all. This is a cruel joke for thousands
of rural patients waiting patiently for dialysis and renal transplant
in villages which are cut off from the world every rainy season
and where electricity does not flicker even for an hour. Stories
about untimely death in rural health-care clinics make a big splash
in the dailies. But sadly the fact that thousands of life-saving
operations which are being performed all over the rural areas, without
even the minimum facilities being available, and under severe financial
restrain are totally ignored.
The brave surgeons who perform such operations are harassed by questions
in the consumer court such as "Why didn't you do the Hb?"
"Why didn't you do kidney profile test?" "Why did
you employ unqualified paramedics to give injections?" The
decision to bring Rural Medical Care within the C.P.A. has been
made by people who have no concept of the reality of how the 70%
of rural population of India receive their health care. As it stands,
the C.P.A. is a deterrent to any young surgeon, planning to set
up a modest rural clinic of his own. He will no longer have the
courage to attend even the simplest procedure at home. Instead of
taking the necessary curative measures himself, he will be desperate
to shift the onus of responsibility to a sophisticated nursing home
in a city centre. The patient who has no means for this city treatment
will be abandoned, and the doctors dream of being a 'rural surgeon'
will be lost forever. To prevent the loss of such desperately needed
young surgeons to the rural area, it is essential to remove the
elements of fear and apprehension from the mind of the rural surgeon.
The law makers need to make a realistic reassessment of the rural
scenario and make some practical adjustments or changes in the C.P.A.
Rural clinics should be removed from the C.P.A. and only 'negligence'
should be a point of criticism against the medical practitioner.
This would immediately reverse the trend of referring patients to
urban centres unnecessarily and rural practice would be allowed
to continue it's service unhindered.
The Clinical Establishment Act also needs to be reviewed in relation
to small rural surgical clinics. It is quite illogical that the
tiny, frequently single-handed run rural clinics which provide at
least 60% of the immediate surgical needs of the rural population
of India, should be equated with full Nursing Homes of 25 or more
beds. It is of course praiseworthy that an attempt is being made
to ensure acceptable medical standards, but the small-scale rural
surgical clinics are a special category. They require a set of 'guide
lines' which takes into consideration the fact that the essential
'basic amenities' of Gas and Oxygen supply, running water and a
regular power supply. Simply do not exist in the area in which the
clinic is most desperately required. Instead of crushing small surgical
clinics out of existence, by heavy handed regulations. some sensitive
and imaginative assistance is required from the government. Interest
free loans could be made available to young doctors prepared to
set up a surgical clinic in the rural area, to provide basic minimum
needs. Special help could be arranged to provide Oxygen and anaesthetic
gas to doctors in remote areas, on a regular basis at controlled
rates. Doctors could be assisted to invest in more sophisticated
diagnostic equipment and steps could be taken to ensure that medical
companies which provide such equipment, are also legally bound to
provide adequate servicing on site in the rural area.
Financial incentives could be given to nurses and paramedical workers
prepared to work in rural areas. Finally. educational opportunities
should be provided to enable the rural surgeon to attend seminars
etc. and for his children to receive adequate education which is
frequently not available in the rural area. Before any 'minimum
requirements for nursing-home registration' regulations are passed,
it is essential that the particular problems of small-scale rural
surgical clinics are carefully considered and steps are taken to
ensure that they are not stifled out of existence by over-zealous
and myopic legislation.
A review of the C.P.A. and the clinical establishment act may be
enough to save the small-scale rural surgical clinics but where
are the surgeons who are brave enough, and confident enough to overcome
all obstacles and settle into a rural practice? Increasingly, the
trend of today, is for the budding surgeon to launch into his post-graduate
specialty while the ink on his M,B.B.S papers is still wet. He has
had no experience at all of life outside, the 'security', and I
the infrastructure his teaching hospital provides.
For my second course of prescribed treatment for the ailing "patient",
Rural Surgical Care in India, I would call for a complete rethinking
on our present system of post-graduate surgical training. It is
high time that a drastic change should be made to the current system
of postgraduate surgical training, which closely adheres to its
Western Model. It encourages early specialization in restricted
fields and at best can serve only a small fraction of the surgical
needs of the country. Specialists have a tendency to blossom into
"Super Specialists' and when they cannot find scope for their
specialty in India, they flock to 'Centers of excellence' in other
countries, and India looses a precious resource. The need of today
is for a thoroughly competent general surgeon able to tackle whatever
challenges he faces, often in extremely difficult circumstances
without the support of a full-scale hospital behind him.
To create such a surgeon, A.R.S.I. Envisages introducing a fully
comprehensive "M.S. in Rural surgery" as another option
in the entrance counselling for post-graduate surgical training.
At completion of training, the surgeon would be competent in the
basic operations of all specialties, with a course in preventive
and social medicine added to the curriculum. There should be residential,
practical training in surgery, Gynaecology, Midwifery, Orthopaedics
and a few months each in Thoracic surgery, Neurosurgery, Paediatric
surgery and Anaesthesia, with associated exposure in an I.C. Unit.
It is only this type of multi-disciplinary residential training
that will give the rural surgeon enough confidence to tackle the
diverse surgical problems he will encounter in practice.
"Importing" a specialist in a specific field into the
rural area is unsatisfactory, as they tend to confine themselves
only to their specialty. For example, a M.S. Gynaecologist will
refuse to have anything to do with a case of appendicitis or perforated
D.U. in the absence of a general surgeon, and will invariably refer
the case to an urban centre. Similarly, a M.S. general surgeon will
refuse to do a Caesarean Section in the absence of a gynaecologist
who happens to be away attending a seminar or a conference. This
happens frequently and the patient is passed from centre to centre
like a ping-pong ball. A mastership in rural surgery, with multi-disciplinary
training, would prevent countless such refusals and earn the heartfelt
appreciation of the rural patient.
It is not possible to layout all the details of this concept in
the limited time available here. But I would like to mention one
important feature of the envisaged course. District and sub-divisional
hospitals should be utilized to provide practical "hands on"
experience in the different branches of surgery. These hospitals
are a gold-mine of experience in their wealth of clinical material
and would help develop a realistic approach to the problems, which
are encountered in rural surgical practice. Advanced technology
may be lacking in many cases, but clinical skills are at a premium
here. Moreover the student will be exposed to the economic conditions
of the patients and learn how to temper his approach accordingly.
Such a radical approach to post-graduate training would obviously
require the imaginative co-operation of a number of august official
bodies if it is ever to gain acceptance. However, granted such acceptance,
the A.R.S.I. could help the medical administration to formulate
a full and intensive practical training leading to the most desirable
and most needed degree of M.S. in Rural surgery. I hope that it
may happen!
In case, I have sounded discouraging and pessimistic about the future
of rural surgical care in India, let me reassure you that this is
far from being the case. We are still a young organisation, only
10 years old, the next 10 years should prove a challenging assignment
to all of you with a spirit of adventure and the will to succeed
against all odds.
Drawing conclusion based on my own experience, after 33 years in
a small single-handed practice, I would say that a well-founded
group practice would alleviate many of the problems I have encountered
along the way. I believe the friendship and character development
which would invariably grow amongst classmates on the M.S. (Rural
Surgery) outlined above, would also facilitate the setting up of
a compatible group practice at a later stage.
I would like to see an extensive increase in the reach of our organisation.
There are still many surgeons working in isolation in remote places
who are unaware of our existence and unable to benefit from the
particular fellowship we offer each other at such occasions as today.
It is essential that every encouragement be given to these young
surgeons because India is facing an acute short-fall of surgeons,
willing and competent to work in the rural area. It would be a practical
and reliable contribution to our cause if A.R.S.I. was to organize
a full profile of all surgeons working in the rural area today,
so that a realistic appraisal may be made of the number of surgeons,
the rural areas of India will require in the next 10 years.
In this era of super specialisation, there seems to be a huge gulf
between the professional academics with their fascination for 'hi-tech'
diagnostics and minimum invasive surgery, and contemporary Indian
Rural Surgeons. The "Whizz-kids" of modem surgery in India
remain enclosed within their own sophisticatede circle. Not for
them the problems of how to obtain a histopathologist's report or
fill an oxygen cylinder, while working in a remote rural area, and
yet the aim of all of us is same, how to provide the most effective
and economical surgical care to our patients. It is for us in the
rural area to reach out to our super specialists and help them become
aware of the reality of surgical needs in the rural area. Through
our news letter we must involve ourselves in debate and seek out
an interchange of views with our specialists, on the vital contemporary
issues, which concern all of us. I believe that the concerted efforts
of our organisation can lure the academics from their ivory tower
and open their eyes to the needs of surgical care in rural India.
I am proud that A.R.S.I. is no longer a 'fringe' organisation but
is a fully established association, recognised at home and abroad.
There are many friends of our cause who have helped to nourish our
association over it's first 10 years. We have grown from strength
to strength with the support of our founder members, the late Dr.
Sushila Nayar, Dr. Balu Sankaran, Dr. N.H. Antia and Dr. Tongaonkar.
I am indebted to all the members of our Governing Council, not least,
to our secretary Dr. S.Shivade, who has sacrificed his rare free
time to keep our organisation running.
Let me remind you all that, although the recovery path may be stormy,
the "Patient" -Rural Surgical Care in India- is alive
and making reasonable progress !
And, on this cheering note, I would to conclude my remarks by sharing
with you written by our revered Rabindranath Tagore, loosely translated
by me:
Play thy tune in me,
With the same tune you play in the morning light
Play Thy tune in me.
Play Thy tune in me
With the same tune that you filled with music, a lost language
The tune that you played on the “life-flute” of a new-born
child
The tune that you played on the smile, on the mother's adoring face.
Play Thy tune in me.
Clothe me with the same garment
That thou has clothed the dust of the earth, As the “Sandhya
Malati” clothes itself With its own sweet fragrance.
Clothe me with the garments
Which make me forget “self” with joy.
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