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Battling against odds

Rural surgery is not an easy game; nor is it the last resort of the unsuccessful. It is a vital organ of the health care of the nation. KAVERY NAMBISAN profiles a little-known organisation that specialises in taking medical help to those who lack access to it.

I ATTENDED a surgical conference in Vapi, Gujarat, at a time when the State was very much in the news for the wrong reasons. It was the annual meet of the Rural Surgeons of India. Vapi was pleasingly serene. The conference comprised of lectures, paper presentations, live video demonstrations of new surgical techniques and the usual banter between surgeons. There was no photographer in sight. With just over 50 participants, interaction was easy.

It took me an hour or so to realise that the reason for the sedateness of the event was the absence of drug companies with their persistent plugging of wares. Professional conferences are usually held with the blessings of one or more multinationals, which creates a platform for the promotion of drugs and equipment. The rural surgeons had decided that they would not ask any company to sponsor their conferences. The dozen or so members who have been with the organisation since the beginning were the life-blood of the event. Dr. Sitanath De, robust, touching 70, and full of verve, from Jhargram in West Bengal, Dr. and Mrs. Tongaonkar from Dondaicha in Maharastra, Dr. and Mrs. Prabhu from Shimoga, Karnataka, Dr. and Mrs. Banerjee who run a 25-bed hospital in the outskirts of Delhi, Dr. Sadanand Misra from Orissa, Dr. and Mrs. Shivade from Lonand, Maharashtra and Dr. Abhayankar from Vapi.

The conference was anything but laid-back. On the first day, reputed surgeons from Mumbai gave live demo of laparoscopic surgery. The operations were performed in a hospital in Vapi, half a kilometre from the venue and the delegates viewed it on a screen in the conference room. In the audience, several surgeons quietly discussed how much easier it was to tackle the problem by an open operation. Dr. Udwadia of Bombay made an impassioned appeal to "embrace" laparoscopic surgery boldly, and take it to the rural masses. It could all be done for a mere Rs. 10 lakhs or so, he assured us. I was getting ready to voice my dissent when Dr. Banerjee spoke: "It has taken us 20 years to develop our hospital from three to 25 beds," he said. "We struggle for the most basic requisites. Laparoscopy would be nice but for most of us there are other, more urgent, priorities." The speaker was sporting enough to acknowledge this truth. Laparoscopic surgery was miraculous, but it was not a priority in rural areas.

What were these priorities? Speakers who followed proved that rural surgery was not an easy game; nor was it the last resort of the unsuccessful. A rural surgeon had to battle against enormous odds. He trained his own nurses, paramedics, and junior doctors; he worked in operating theatres where lights were faulty, facilities minimal and air-conditioning a distant dream; he bought his own equipment and struggled to maintain them. The rural surgeon spends precious time, energy and money because of indifferent suppliers. Then there is electricity, water, oxygen, drugs. Money. What about the family? Kids? Education and entertainment?

Dr. Shrikande of Mumbai, in his guest lecture titled "Excellence in Surgery" reinforced the time-honoured dictum of simplicity. The surgeon's duty to the patient is to improve the quality of life. Only that. She/he must question him/herself constantly and not be afraid to change when change is necessary. He was critical of the over-dependence on scans and x-rays and the diminishing strength of clinical acumen among doctors. The essence of surgical leadership, he said, is a combination of courage, skill, experience, knowledge — and humanism.

Between busy schedules, I asked Dr. Prabhu and Dr. Banerjee about the origin of the organisation. Like the veteran Dr. De, they had returned to India after training in England, along with their doctor wives; they had decided to work in remote areas, away from cities. As qualified surgeons, they were members of the Association of Surgeons of India.

A rural surgeon did a wide variety of surgery because there were no specialists to palm them off to. In addition to general surgery, he did gynaecologic, paediatric, urologic and orthopaedic surgery. Some doubled up as their own anaesthetists, worked without proper lab or blood bank, with untrained staff and poor facilities. But mainstream surgeons ignored the needs of those in rural areas. When they requested that funds be allotted to form a separate section to address the need of rural surgery, the Association of Surgeons rejected it.

This rebuff spurred them to think of an alternative. An exploratory meeting was convened in Shimoga, Karnataka in 1992, to discus the issues: 70 per cent of India's people live in villages and have little access to health care. A mere five per cent of our people get excellent medical facilities, 15 per cent have the means to obtain average care and the remaining 80 per cent (the rural, along with the poor urban population) are neglected. A decision was taken to start an independent fraternity, which would address the needs of rural surgeons.

Among those who encouraged this move and guided the members in laying down the infrastructure were Dr. Balu Shankaran who had retired from government service and Dr. Antia, a plastic surgeon. Rural surgery was a vital arm — no, an arm and a leg — of the health care of the nation. It had to be nurtured.

The new association resolved to encourage the practice of rural surgery by networking; evolve technology appropriate to local needs; conduct continuing medical education to the members; and make surgery available to rural population at an affordable cost. In a bold move, they enlisted as members of the association any doctor who had been practising surgery in a rural area for more than five years, even if he or she did not have a degree in surgery.

The first conference of the Association was held appropriately, in Sevagram, Wardha where Mahatma Gandhi — that genius of common sense — started the movement to make villages self sufficient. Delegates to that first conference included a team from Bangladesh. Conferences have continued every year. There are 60 life members, including some from the United States, Canada and Australia. Last year a decision was taken to start a three-year diploma course in rural surgery, in order to give the benefit of all-round training, so essential in the villages. The response has been very good.

I listened and learned. Dr. Masurkar, who preferred to think of himself as a Super GP rather than Super Surgeon had over the years, removed 900 foreign bodies stuck in the windpipes of children, a procedure, which is hazardous even in well-equipped centres. Jayant Patel had brought the expertise of urology to Valsad. K.C. Sharma from Udhampur is a wonderful example of how versatile a rural surgeon can be. Dr. O.P. Narayan from Dhanbad, Bihar, astonished us with his success in the use of local anaesthesia, even for major abdominal surgery. Dr. Tongaonkar has been holding free surgical camps for the poor in his village every year. Dr. Banerjee and his team find time to implement innovative techniques in surgery. Rural work is often thought of as a self-punishing austerity meant only for nuns, sadhus, missionaries and retired doctors. Here were men and women who applied themselves to their work with verve and commitment.

One couldn't have asked for more out of a conference. As I sat in the train chugging away from Gujarat, I was pleased that for the 80 per cent of our people who have little access to medical care, things have begun to change. I saw it in Vapi.

The writer is a surgeon and novelist whose latest novel, On Wings of Butterflies, is published by Penguin India. E-mail:

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