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The neurosurgeon in the village

A senior doctor travels beyond his comfort zone, and develops a grudging respect for government health schemes in a system of inclusion that actually works.

I was upset with Chetan Bhagat. His book Half Girlfriend had got the geographic dimension of Central Park, the cab trip from the JFK airport to the Upper East Side in New York City, all wrong. Having stayed on the upper end of Central Park for nearly two years, it seemed an unpardonable way to introduce hapless Indian readers to a city I had called home.

I had recently returned to Bangalore with family after completing two neurosurgical fellowships on both coasts of the United States over a period of three years. The thick endearing accent on the local customer-care help lines was evident when I called the 1800 numbers to update my new contact de-tails at the bank, the cable network and the mobile service provider. Public utilities took time to register, even longer to deliver — contrary to the online efficacy with which I connected, paid bills and disconnected my electricity connection at Stanford, California without ever meeting a utility provider.

In Bangalore, we took a home on rent which was mid-way on the hypotenuse which lined the hospitals where my wife and I worked, with my daughter’s school at the right angle. I even noticed a classmate from high school, who I called out to, gesturing animatedly. But he turned away and dodged me with alacrity that would do a pot-hole dodging two-wheeler proud. This promised to be a fun neighbourhood, anyway, Bangalore was the new Manhattan.

A visit arranged

I started connecting with friends from the hospital of my previous employment, my medical college and with family to get the social network going. I called Dr. Rahul, my friend from pre-university college in Mangalore who is now a plastic surgeon. He had set up a small-size hospital with a group of like-minded physicians in rural Bangalore. I was told their team would be happy to have me visiting the hospital and he WhatsApp-ed the address. On Google Maps it would take me an hour and 10 minutes to get there with 10 p.m. traffic. I set my visits for 5-30 to 7-30 p.m. every Monday. My bag contained a cheap Chinese flashlight, a knee hammer to check tendon reflexes and an ophthal-moscope (which helps identify raised brain pressure) gifted by a senior eye doctor and family friend when I began training to be a neurosurgeon in 2002.

I left my current work-hospital in north Bangalore at 4.30 p.m. on my first visit and then took route 44 from the Hebbal flyover, crossing many real estate projects waiting for the next investment cy-cle, and beyond the toll booth and turn to the international airport. After bypassing the newly pro-moted suburb of Devanahalli I took a sharp left to enter highway 648. The milestone said 19 km to destination. The highway was being levelled and bitumenised in stretches, and I spent 30 minutes covering the distance, playing musical chairs with heavy trucks. Ingenious truckers progressed from “We two ours two” public service messages decades ago to more personalised declarations of “Maa ka Ashirwad” and “Don’t kiss me” on their bumpers. I enjoyed the various other resourceful com-binations of English, Devnagari and numbers meant to convey road etiquette. I cleared two manned railway crossings on the Chikballapur and Hyderabad lines. “Rob work under progress, inconven-ience regretted” read a worn-out sign at one crossing. The trucks exchange positions with tractors which now moved in slow gear. I then made my way bordering a vineyard (closed on Mondays, ob-viously), a listed heavy construction and equipment facility, rows of 60x40 residential layouts carved into the hearts of previously healthy fields. I reach the municipal town on time, locate the hospital on a cross road and park on an empty plot between a timber retailer and a walk-in-and-crawl out bar.

The patients come

For the first two visits I sat for two hours and mastered advanced levels of Candy Crush, refusing any in-app purchases and confidently advanced to higher levels. I was on patient zero till my third Monday visit. He was a shy male, 20, straight out of a Malgudi Days caricature — who wanted guaranteed extra-power medications for conjugal bliss. He was sure it was nerves in the erogenous region letting him down and wanted the best magic potion. I told him it was outside my area of ex-pertise, referred him to a urologist and offered him a full refund of professional charges at the front desk. Sensing no further walk-ins I asked the hospital to intimate me telephonically when patients arrived and then went downtown to buy local produce. All was quiet from the hospital, so I took the road home, stopping at a petrol bunk to tank up, handing over my credit card. The pump had a swipe-first fill-later policy.

Given low card-usage in the area, the manager had forgotten to replace the paper roll and he had no proof of card usage authentication. I showed him the SMS proof of the transaction and urged him to fill petrol for the Rs.2,000 swipe. He flatly refused. We called the point of service and credit card helpline to give us verbal proof of authentication. After numerous 1800-number dials and unyielding service representatives, the banker to the nation confirmed an unbilled transaction on my card. I reached home at 10 p.m. I counted Rs. 140 in toll and about a thousand rupees in fuel for each trip with no patient credit. The Monday clinic was not getting any-where and the heavily skewed cost-benefit ratio was working against me.

After a month, patients started trickling in. A farmer with chronic back pain, a young lady with mi-graine who required further evaluation. Kannada had bestowed the word nara to blood vessel and nerve. This nara doctor had patients with varicose veins, smoking and atherosclerosis-related arte-rial disease in the clinic. A degree in general surgery before neurosurgery training equipped me le-gally and clinically to examine and recommend appropriate treatment. These patients had no scans or lab reports when they visited the clinic. No Internet search results or second opinion recommen-dations here. A tumour in a child was localised to the cerebellum, a part of the brain involved in maintaining balance. He was rushed for immediate investigations and surgery. A strict vegetarian had a Vitamin B12 deficiency affecting part of her spinal cord and causing her numbness. A child with a head tilt had a congenital skull malformation. Middle-aged farmers had degenerative spine disease from years of toil in the field. Most of them however, wanted someone to listen to them, a housewife with chronic depression, wife of an alcoholic who wants some good sense instilled in her husband defaulting on his rehab treatment, a septuagenarian with an old stroke and paralysis who was considered a burden by his family and wished that he had passed away, a hypochondriac who visits every week with migrating pains, a mother of a six-year-old differently abled girl who was hoping for a miracle foreign cure to a permanent situation.

Re-reading time

Over weekends I began re-reading textbooks to recapitulate basic neuro-pathologies that had been buried during three years of super-specialised fellowship. These were not the patients who could afford $1000 a pop micro-catheters to bust a clot or coil and aneurysm, or undergo a brain bypass procedure, unlike the IT royalty of the Bay area or the financial or political mighty of New York who would condescend to gratify you with a selfie at hospital discharge. My current patients couldn't afford even a heavily subsidised MRI scan. They were mushroom and jackfruit growers, sellers, milkmen and silkworm-rearers. I was thrilled to learn that there were government schemes for patients like them, those below the poverty line, teachers, and children to the age of 18 and police personnel. These programmes were mostly run by the government of Karnataka, larger schemes such as those for children, the Pradhan Mantri Swasthya Suraksha Yojana were under the Central government. The financial limits offered by the Employees State Insurance (ESI) scheme are at times unmatched by the assured sums of private insurance companies. Treatment could be availed for virtually any disease of any specialty at government or private medical colleges and hospitals on do-miciliary basis through ingenious schemes.

Government schemes work

I saw patients with chronic epilepsy being given regular free monthly supply of medications at a premier neurological institute in Bangalore based on a special ID card. The rural patient is no longer the subservient person who would take in as the ultimate truth everything that he is told. He now understands, debates, questions, clarifies, and is aware of various avenues of treatment, medical or surgical. My former scepticism of government health schemes saw me shifting to a grudging re-spect to a system of inclusion that works. To see them work now is green-shooting towards comprehensive universal healthcare inclusion, a start-up to the advanced but socialised healthcare sys-tem in Scandinavian countries. The way forward for listed and private healthcare India Limited is to keep their basic costs running using these mass state schemes and depend on for fee patients for their bottom-lines while providing standard of care to both.

I travel 50 km each way every Monday evening. I pass the usual suspects en route. The cross-dresser with extensive face and hand burns under the Hebbal flyover who only accepts currency notes and not coins offered to him at the signal, the traffic police with their speed gun on straight stretches of road, the toll gate attendants who hand over a return pass, and numerous village medicine and piles-fistula treatment shops.

Not many of the patients I see translate to operable neurosurgical cases. Return on capital employed and cash flow is still negative. These are not Dr. Ernesto Guevara’s motorcycle diaries. For two hours it’s payback time, practising clinical medicine as it was half a century ago before the advent of advanced radiological imaging. I’m also enjoying this town before it soon becomes another concrete suburb of Bangalore.

I’m not angry with Mr. Bhagat anymore. I don’t really care if his misdirected GPS takes him on a dive into the Hudson River while he plays Pokemon-Go in New York City.

(The author is a senior consultant neurosurgeon at the M.S. Ramaiah Memorial Hospital and the M.S. Ramaiah Medical College in Bangalore. E-mail: sunilvf@gmail.com )

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Printable version | Apr 9, 2020 1:45:10 AM | https://www.thehindu.com/opinion/open-page/The-neurosurgeon-in-the-village/article14545976.ece

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