A city surgeon once accused me, "Your area is under-utilised by specialists". What he meant was that our team—who managed 90 per cent of our patients ourselves—denied him the heroic Visiting Surgeon status. Most of the time, city surgeons hare down to a peripheral hospital more than a 100 km away, operate with one eye on the clock and leave behind disasters. Many do great work in the cities but they cannot answer the problems of rural people.
Seventy per cent of our population lives outside the cities but eight out of ten doctors and a shocking 80 per cent of all hospital beds are urban. Every preventable malady, like tuberculosis, malaria, diarrhoeal diseases, is many times more prevalent in rural India; so are infant and maternal mortality.
The government wades through its five-year plans, trimming health expenditure to levels below that of Bangladesh and Sri Lanka, and blindly enforces laws pertaining to healthcare. Take the example of blood transfusion. The government insists on blood banks, even though they are notoriously expensive to establish and maintain. The power supply in rural areas is erratic and there is a constant danger of the deterioration of stored blood. Hundreds of rural surgeons practise the use of fresh blood transfusions after performing all essential tests as specified by WHO for absolute safety. Thus, every time rural surgeons use fresh, pre-tested blood, perform high-risk operations and save lives, they break the law.
Privatisation of health has led to the boom of city hospitals. The government's decision to increase the number of medical colleges will feed the already overfed cities. Specialists in the metros suggest telemedicine for the villages so they can "see" the patients long-distance and advise treatment. Some suggest that alternative medicine will suffice. The underlying assumption is that those who are stupid enough to live in villages should take the leavings of city practices. The supposition that anything will do for the villages is offensive. The few skilled doctors who go to the villages do work that needs many times their number. Here, often without electricity and always without state-of-the-art equipment, they treat the critically ill and do major surgeries.
Only a few doctors and social organisations try to reach out to rural areas. Examples of those who do sparkle from every corner of the country, but they are few, and not publicised. We need more doctors who are multi-skilled rather than super-skilled; and hospitals with low-cost technology to make treatments affordable.
Policymakers insist that every skill needs a recognised stamp, a degree. But the credentialed professionals cling to the cities, citing the lack of facilities in the villages. If they don't go to the villages, how will there be facilities? Surgeons need anaesthetists, nurses and trained technicians to operate. The only solution in a village is to train your own team. In Bihar and later in UP, I operated on gunshot wounds and severe crush injuries which were as common as a ruptured intestine or an appendix. The anaesthetist who did not have the postgraduate qualification and the nurses who were trained by us were as good as the best I have worked with. If being competent and saving lives when no else will do it is against the law, rural doctors are quite happy doing it.
The Association of Rural Surgeons of India was set up in 1992 and is now around 500-strong. At its annual conference (which is no five-star jamboree) rural surgeons present innovative, low-cost techniques. Here I learned that sterilised mosquito-net material is as good for a hernia repair as the expensive prolene mesh which surgeons routinely use. It cuts the cost from Rs 3,000 to Rs 30—and the results are as good.
For doctors in rural areas to be competent, good training, continuing education programmes, annual audits and research are essential. Without these, surgical standards will slip. Surgeons who know this have been trying to convince the government to start a training programme in rural surgery. This year the Union health ministry has agreed to the training of multi-skilled surgeons in rural practice. If all goes well, young doctors will have a new speciality to train and work in.
Rural surgery is a speciality. The doctor must have many skills and the confidence to work under very difficult conditions. There is plenty of work, the gratitude of patients, and high adventure. And the quality of life? Where else will a patient reward you with two juicy cucumbers or a plump river fish for having operated on him for a bull gore injury, a ruptured intestine or a motorcycle accident?
(Kavery Nambisan is a surgeon and novelist. Her last book, The Hills of Angheri, is a doctor's story of conflict between city and rural health. E-mail: firstname.lastname@example.org)
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