||Eur J Surg 1999; 165; 69-71
Rudolph Virchow said medicine is a social science, (8) ….
Today this concept of medicine must enter into the larger political
and social life of our time.
The combined population of North America and Western Europe is
about 650 million, while 1.2 billion people live in China and
950 million in India. Surgical practices that are appropriate
in North America or Europe may not be applicable in a rural setting
in India or China. This is because most people in these countries
are content to live in a simple style, in harmony with nature,
and with a much lower per capita consumption of natural resources
than westerners (or, for that matter, the rich and powerful Indians
living in the large cities in India).
Nevertheless, 70% of the Gross Domestic Product of the nation
is made by people who live in rural areas and urban slums of the
country. It is this category of people who have very little access
to basic modern surgical care. Also 80% of hospital beds in India
are in large cities, and 80% of those beds are occupied at any
time by people who live in rural areas (T N Krishnan at the second
National Conference of Rural Surgery).
The Indian burden of external debt repayment has increased by
30% in the past five years, but the city of New Delhi alone has
imported more CT scanners, MRIs, and ESWL machines than the whole
of Norway and Sweden put together. Most of these are in the private
sector, out of reach of 90% of the population.
At the third World Congress on Surgical Efficiency and Economy
held in Kiel in September 1995 it came to light that transplant
programmes in middle eastern countries were being jeopardized
by private transplant programmes in India, where kidneys were
available for sale. Oil rich patients came to India for treatment.
A law has since been passed banning such transplants.
and Total Health Care
In this social background, the concept of Rural Surgery took birth
in India. One of the demands of the Alma declaration of the WHO
which India is a signatory was that a proper referral system
must be developed as a part of total health care. This is lacking
in most developing countries, including India. A large number
of medical colleges and private hospitals have sprung up in large
cities, all without any proper referral system to cover the rural
population. As a result even today women die of obstructed labour
in the countryside while transplants and bypass operations are
being done in the large cities.
The medical colleges are producing about 600 qualified surgeons
every year, but scarcely half of them take jobs in urban hospitals.
A few go abroad to the Middle East. Europe, and USA and are lost
to the nation. The rest start their careers as surgeons in impoverished
voluntary hospitals or district hospitals in the country-side
or set up their own private clinics where they charge fees that
the people can pay. Of necessity they combine general practice
with minor surgery to start with. They train local boys and girls
as assistants and gradually expand their activities. They start
providing all types of second level surgical care including obstetrics
and gynaccology, orthopaedies, urology, and general surgery. They
also provide preventive services and health education. So, although
they are trained as surgeons to start with, they end up giving
total health care by using locally available human and material
resources and combining these with their western medical knowledge.
Some of these surgeons have started doing laparoscopic operations,
endoscopies, and transurethral resections, even oesophagectomies
and abdominoperineal resections.
The Birth of
the Association of Rural Surgeons of India
The Association of Surgeons of India, established in 1938, now has
more than 8700 members. Some of them, who practice in remote rural
areas and in small towns, requested the council of the Association
to arrange programmes of teaching relevant to their practice and
to hold a symposium to highlight their work. The Association agreed
and in 1986 held a symposium on Surgery in rural areas during their
annual conference. This brought to light the varied work that they
were doing under difficult confitions. The Association then decided
to form a Rural Health Care Committee, to give it three half-day
sessions at annual conferences, and to survey the working conditions
and training needs of the rural surgeons. Dr. R.R. Prabhu of Shimoga,
Karnataka was made convenor of this committee.
A questionnaire was circulated among the members of the Association,
151 of whom responded (142 practising in rural areas) (5). Half
were in government hospitals and half in private practice. The
survey showed that:
- 45% worked without a specialist anaesthetist
- 63% had no blood bank facilities.
- 68% worked without a qualified radiologist.
- 68% worked without a qualified pathologist, and
- 32% had none of the above facilities.
|Analysis of the work done
- 96% did abdominal operations
- 68% did orthopaedic operations
- 80% did obstetric and gynaecological work
- 81% did urological operations
- 30% did thoracic operations
- 16% did ENT operations, and
- 66% did three or more of these types of operation
These findings were presented by Dr. Prabhu at the annual conference
of the Association of Surgeons in 1988. As a result more than
60 members sent a memorandum to the council of the Association
requesting training facilities for rural surgeons in multiple
disciplines, and acceptance of rural surgery as a speciality.
This request was not accepted by the Association, and so, inevitably
the Association of Rural Surgeons of India was formed.
Conferences of Rural Surgery
The first national conference was held at the Mahatma Gandhi Institute
of Medical Sciences in Wardha. Its Dean, Dr. Sushila Nayyar, presided.
There were more than 100 delegates, including a few from Bangladesh.
A book was published to outline the work of the Association (I),
and a quarterly newsletter was started.
By September 1995 when the third conference was held in Delhi
115 surgeons had joined the new Association. The keynote address
at this conference was given by Dr. H. A. Gezairy, Regional Director
of the Eastern Mediterraneam region of WHD (3). In his address,
“Let me return to those surgeons in India who, as I understand,
have settled down in rural areas and through their ingenuity have
mobilized and trained a group of paramedies as anaesthetists;
have established a procedure, in spite of numerous constraints,
through which asepsis at various levels is ensured; and even developed
facilities for blood transfusion through their dedication to the
community….. They have in the process accumulated invaluable
experience, which needs wide dissemination for others to emulate.
This is not the experience of a few adventure-inspired surgeons
but of a large number of them with basically the same background,
the same objectives, and working more or less with the same constraints……
I would go a little further by suggesting that rural surgery be
developed as a specialty for the training of fresh medical graduates
followed by practice of rural surgery in an appropriate setup
during their rural internship in community medicine, which I understand
is an obligatory part of medical training in India.” One
of the activities of the new Association was to liase with the
Medical Council of India, the body that deals with the setting
of medical curricula in the country. At least one university,
the Indira Gandhi National Open University, has agreed to start
a continuing education programme for qualified surgeons to equip
them to practice in rural areas.
of the Association of Rural Surgeons
The Association of Surgeons of India has finally agreed to accept
rural surgery as a specialty, and the Assocation of Rural Surgeons
of India has adopted the following programme:
in Surgical Care
- It holds annual conferences to discuss and solve problems
of surgeons working under resource constraints. This involves
increasing our network and membership
- It sets up standards of activities and procedures based
on the experience of surgeons already practicing under
- It encourages yound surgeons to start practices in
- It is collaborating with the Indira Gandhi National
Open University in designing and developing a Certificate
Course in Rural Surgery to enable surgeons to work amongst
impoverished communities with limited resources
- It spreads our concept to surgeons of other developing
countries through international conferences and journals
- It activates rural surgeons to audit their work in
a form that will be beneficial to other involved in similar
Variations in surgical technique and care have come to light that
suit rural practice. Most surgeons are still doing open prostatectomies,
cholecystectomies, appendicectomies, and herniorrhaphies. In most
rural hospitals the patients’ food is provided by relatives
who also do some of the nursing. It is at least 10 times cheaper
to have surgical services of this type within a few kilometers of
their homes. To have more sophisticated services in the western
style they and their relatives have to travel 50 to 100 or more
kilometers to an alien city and bear the cost of their stay there
as well as losing their income during the period.
A plastic surgeon in a small town has started using pigskin as
a temporary wound cover for extensive burns. A few surgeons have
established autotransfusion for elective operations (4.6). Some
surgeons (myself included), who have no facilities for endoscopic
or operative cholangiography, do choledochoduodenostomies for
patients with common bile duct stones and a dilated duct. One
surgeon who handles large numbers of hand injuries has devised
a lock for corn chaffing machines to prevent these accidents (2).
Some surgeons train village health workers to suspect and detect
early cancers and bring these patients to the doctor. Autotransfusion
for patients with ruptured ectopic pregnancies is commonly practiced
by rural surgeons. As for suture material, silk and cotton thread
are still used for superficial stitches without any adverse effects,
and this saves the cost of imported suture material.
The whole purpose is to provide optimum surgical care to impoverished
communities around the world within limited resources. If the
community cannot afford sophisticated investigations and laparoscopic
surgery, clinical judgement with minimum investigations and open
surgery will have to continue. If the community cannot afford
to pay for superspecialists the generalists will have to provide
Today in the rich countries of the west the finances of both
national and private health care are under great strain. Managed
healthcare and Health Maintenance Organisations are more and more
popular, while at the same time the trend towards private medicine
accelerates. In the developing countries we have to learn our
lesson from this, as well as our lessons in high technology. We
therefore ensure a type of appropriate surgical care that the
community can afford. As the community grows richer rural surgeons
can invest in more advanced technology.
It is unfortunate that India has become a dumping ground for
advanced equipment, particularly in the private sector, to the
detriment of ordinary people. Such imported equipment should be
restricted to the 150 medical colleges in India. Private hospitals
that have spriung up in large cities, mostly by selling shares
“investing in the bright future of health care”, are
a drain on the country’s resources. They glamourise high
technology and prevent young surgeons from taking a pragmatic
view of the health needs of the vast majority of people in this
Submitted March 25, 1997; submitted
after revision January 15, 1998; accepted March 5, 1998.
- Banerjee JK Concept and practice of rural surgery B.I.
Churchill Livingston, New Delhi, 1993.
- Chaudhuri B. Prevention of surgical accidents as part
of total surgical care, Rural Surgery 1994; 3: 33-35.
- Gezairy HA. Rural surgery, a giant leap towards primary
health care. Rural Surgery, 1995; 1: 3-7.
- Narayan OP. Autotransfusion in routine major surgery.
Rural Surgery 1995; 1: 11-13.
- Prabhu RD. A survey of surgeons practicing in peripheral
areas in India: their problems and constraints. In: Banerjee
JK. Concept and practice of rural surgery New Delhi: B.I.
Churchill Livingston, New Delhi, 1993: 9-14.
- Prabhu RD. Autotransfusion of blood salvaged from peritoneal
cavity. Rural Surgery 1995; 1: 8-10.
- Sitanath De. A definitive primary choledochoduodenostomy
for treatment of calculous disease of common bile duct
in a rural setup (45 cases in 23 years). Rural Surgery
1995; 1: 51-54.
- Virchow R Quoted in Straus MB, ed. Familiar medical
quotations. Boston: Little, Brown, 1968: 561.
J. K. Banerjee, MS, FRCS
Rural Medicare Centre
P.O. Box 10,830
Mehrauli, New Delhi 110 030