24/08/2015 8:12 AM IST | Updated 12/10/2016 3:10 PM IST

The Urgent Need For Holistic Surgical Care For A Stronger India


A stream runs through a beautiful village near Mungaoli in Madhya Pradesh. The village's main attraction is the annual cattle fair that brings in farmers from across the region. For the rest of the year, the dusty streets of the village are quiet. Ram Prasad is a 54-year-old farmer who calls this place home. He is happy because he provides for his family and is physically fit. Ram has had a discomfort in his groin for several months. It appeared as a lump a few years ago, but he never thought much of it. The nearest doctor was too far away for him to justify the time away from his fields.

One day, while drawing water from the village well, he feels a sharp pain in his abdomen. He goes home to lay down. His wife goes to find Rekha, the village ASHA, who arrives at their house to find Ram in agony. Ram has a fever and has started vomiting. His hernia looks red and ugly. After examining Ram, she helplessly turns her eyes to the floor. The closest district hospital with a surgeon is 65 km away, and with the evening soon approaching she knows she cannot call anyone to drive them there. The hospital ambulance will not come to her village. Ram dies that night leaving his wife and two children to care for themselves.

"Three-quarters of deaths in India happen at home, without a diagnosis or medical care."

It would be fair to say that we Indians are a proud bunch. We are proud of all Indians' achievements, whether they are in India or abroad. We cheered when Sundar Pichai became Google's CEO, fawned over Michelle Obama's dress designed by Prabal Gurung, and were beside ourselves with excitement when Vivek Murthy became the Surgeon-General of the United States. The medical community, too, is proud of the achievements that our doctors have been making since antiquity. No surgery class in medical schools in India begins without a mention of the revered Sushrutha, a surgeon from 600 BC, who practiced in Benaras. His book, Sushrutha Samhita, is one of the first textbooks of surgery, describing hundreds of procedures. Though the West ignores Sushrutha, we consider him the Father of Surgery. It is, therefore, sad to see that there is little attention paid to the public provision of surgical services in modern India.

This lack of attention is not unique to India. A recent report established that 5 billion people have no access to timely, safe, and affordable surgical care globally. The onus is now on national governments to determine and meet country-specific needs. There are many common conditions that can be cured by surgery: hernias, appendicitis, peptic ulcers, fractures, and many cancers. Even improving maternal health requires access to procedures like caesarean section, which can help both mother and child. Surgery is a cost-effective method of improving health care, and investments in surgical systems pay large economic dividends.

What does this mean for India? How many deaths like Ram Prasad's could be prevented by better-equipped public hospitals? These questions have never before been answered. Three-quarters of deaths in India happen at home, without a diagnosis or medical care. Enter the Million Death Study, begun in 1998. The largest study of its kind, it aimed to collect data on one million deaths in India over a 15-year period to understand the causes of premature deaths and to provide evidence for prevention. While Ram Prasad is fictional, the MDS shows that his story is real. A recent study using data from the MDS showed that in 2010, 72000 people in the country died because of acute abdominal conditions: illnesses like peptic ulcers, appendicitis, and hernias that need urgent surgery. Of these deaths, 87% occur in rural areas, and the vast majority occurs at home, where patients do not receive care and die in agony. If treated promptly, these conditions are usually surgically curable; if Ram Prasad had access to timely, safe care, he would likely not have died. The study showed that round-the-clock access to facilities within 50 km with the appropriate resources is necessary to prevent deaths due to these conditions.

In 2010, nearly half of the country's population lived more than 50 km from the closest public district hospital with 24-hour surgery and anesthesia, critical care beds, a blood bank, a basic laboratory, and radiology. Most rural Indians traveling this distance would need to walk or use animal-pulled transportation, further compounding the problem. The Health Ministry of India has theoretically made provisions for surgical care to be available at community health centers and district hospitals. However, absent infrastructure, a severe lack of resources, and a shortage of trained professionals mean that many Indians have yet to benefit from this policy. But we cannot just blame the system. Lack of health education, loss of faith in the quality of care that is being provided at public hospitals, as well as inadequate personal finances to cover the non-medical costs of care can also cause a person to suffer at home--often until it is too late.

"Three-quarters of deaths in India happen at home, without a diagnosis or medical care."

The provision of surgical care to all Indians is simple and affordable--it requires a political commitment to strengthening health systems, targeted financing for surgery and anesthesia, and a well-developed National Surgical Plan. The WHO recently passed a resolution stating that surgery is an essential part of primary health care. As a member country, India must respond to this resolution. In contrast to many countries, we can take pride in our national data. We know what the problems are, and we know how to fix them. Simply improving resources at existing district hospitals in India could prevent two-thirds of deaths like Ram Prasad's. This will require an investment in infrastructure, and investment in people--the tireless men and women who provide surgery and anesthesia for rural Indians.

A stream runs through a beautiful village near Mungaoli. It whispers the stories of 72000 Indians and hope for a future when all Indians can access safe, affordable surgical care when they need it.

Both authors currently work in the Program in Global Surgery and Social Change at Harvard Medical School, United States.

Like Us On Facebook |
Follow Us On Twitter |
Contact HuffPost India