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.

Rural Surgery 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.

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:

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.

National 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, he said:

“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.

The Work 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:

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 the care.

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 nation.

Training of Surgeons for Practice in Rural Setup