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  The Association of Rural Surgeons of India
Its Past, Present and Future
As I See It
By Dr. N. H. Antia,

Presidential address delivered at the VIth National Conference of ARSI at Dondaicha, Dhule District, Maharashtra, on 13th November 1998.
  The Association of Rural Surgeons of India (ARSI) was a response to the surgical needs of the 90% of our population who live not only in the 7 lakh villages but also in the rural slums. Their needs is for good basic surgery at affordable cost, within easy access and provided in a humane manner; a type of surgery which was provided by the West to their own people in small county hospitals, as personally experienced by me five decades ago. Unfortunately the Association of Surgeons of India (ASI) established for this purpose has failed to ensure appropriate surgical care for the majority of our people to this date.

Like the rest of our neo-elite, in their single minded pursuit of the Western mode of a purely materialistic form of development following Independence, ASI has also been transformed into a conglomeration of ever increasing specialists vying with each other to practice the 'latest' expensive technologies emanating from the West regardless of our country's requirement. This type of medical care is also being eagerly sought by the equally Westernized urban affluent and middle classes to which they have been addicted under the misconception that all that emanates from the West is the best and that cost and effectiveness are synonymous. In search of kudos and lucre the medical profession, which also belongs to this class of our society, has also influenced our national health policy accordingly. This has unfortunately diverted our limited health resources to large urban hospitals and medical colleges regardless of the health and medical needs of the majority of our people. In this they have preferred to follow the US commercialized market oriented model rather than even the more socialized medicine of the capitalist countries of Western Europe. A more inappropriate model to imitate, especially for the requirement of a 'need based' country like ours, would be hard to imagine. Much of this is now proving counterproductive even for the West itself due exponential increase in cost with marginal improvement.

Fortunately for our country I a substantial number of our surgeons have continued to work and thrive in the smaller towns in government rural hospitals and private nursing homes. It is they who are serving the majority of the surgical needs of our rural population since it is not feasible for most of the rural population to seek the expensive specialist services of distant district and city hospitals.

Nevertheless some, even poor, under duress of pain and suffering go to urban institutions often at the advanced stages of the disease resulting in financial ruin to the rest of their family. And yet if a larger number were to do so, these large impersonal institutions would be swamped with such patients. The answer therefore lies in reaching good surgical care to the rural areas rather than patients from rural areas being forced to go to the cities. It is estimated that such form of medical care is the second commonest cause of indebtedness of the poor, next only to dowry .It is hence the responsibility of our profession, to whom the people look up to in all matters concerning health and medical care, to develop a form of health care including surgery, which is in keeping with the needs of our fellow beings and yet be able to live comfortably, as most of our ARSI members do. For this they have to perform more operations at modest cost as opposed to the excessive charges of urban specialist care, since over 80% of the most useful aspects of specialist care can be undertaken equally or even more effectively by the general physician and general surgeon at a fraction of the cost. The innovativeness of our members plays an important role in providing good surgery at affordable cost.

Many of the advances in surgery in the West were achieved during wars working under conditions far worse than those available to our ARSI members. Many of the exotic new techniques and instruments devised during the five decades after the last war have resulted in only relatively minor improvement in the overall health of the people at exponential increase in cost. This actual fact has denied basic health care to most. For this our profession has to accept responsibility, for it has willingly fallen prey to the seduction of the market and the media. In this we have lost the age old values of our profession and have become salesmen for promotion of the drug and instrument industry; all in return for monetary gain and kudos. This is why ARSI refuses to accept support, donations or gifts from these sources.

The globalized market, devoid of morals and ethics, in its single minded objective of financial gain has played havoc in the field of health and medical care, where the only form of protection in such an economy, namely consumer resistance, is at its lowest. Hence medicine under the guise of health has become the fastest growing industry throughout the world today. And yet it is our own state of Kerala which demonstrates that at $ 15 per capita per anum it enjoys a health status almost equivalent to that of the USA spending over $ 4000 per capita or over $ one trillion per anum (equivalent to three times the GDP of our entire country). Despite this 15% of the US population i.e. 40 million people do not have access to basic health and medical care. This clearly exposes the fallacy been cost and good health care so assiduously promoted by the health industry.

The achievements of ARSI and its members in providing cost-effective services in a humane manner at the doorstep of the people at affordable cost should be an example not only to our urban counterparts but also to the surgeons of the other' need based' countries and even to those in the West. It is the duty of ARSI to spread its unique knowledge, achievements and philosophy to them instead of being awed by inappropriate technology.

In its single minded search for monetary gain the globalized market controlled by the Multinationals seeks to polarize the societies of the 'need based' countries. This is in order to create a Westernized consumer oriented market comprised of affluent and influential members in each' need based' country who in turn help to concentrate the natural wealth and cheap labour of their country in urban enclaves so that it is readily available to this market. This minority which thrives in urban enclaves, amidst a sea of abject poverty, In order to enjoy a comfortable imitative Western life style, has lost its roots and culture of its own society. At the behest of their Western mentors they have distorted our country's development and economy in every field, including medicine and surgery to suit the needs of the global market rather than that of their our country; all for a slice of the exported cake.

ARSI seeks to provide a platform as well as support to those who have seen through this maze of deceptions and distortion of technologies and of values unleashed by the market forces on our people. Our members live and work not merely for themselves but also to alleviate the suffering of those who fought for Independence whose fruits we enjoy.

Unless we understand this sequence of events which is responsible for the present scenario and which in our medical parlance is termed as making a diagnosis, our efforts can only result in frustration, or at best in smug self satisfaction as charity which is demeaning to both the giver as well as the taker.

ARSI does not represent an association of second rate surgeons who provide second rate surgery to second rate citizens in second rate rural India or urban slums. It represents those who despite the training and values inculcated in our medical colleges have retained human values and courage to swim against the popular tide which has engulfed many of our profession. We have had the opportunity of studying in government medical college at the people's expense and not in capitation fee colleges to recover our investment. Many of you have struggled under difficult conditions to adapt your surgical knowledge to the requirements of those who most need such services.

ARSI is not enchanted by the 'latest' technology but are practitioners of appropriate technology. Innovation is part of our daily routine. Elegance lies in making the complicated simple and appropriate; not in the reverse. Profit is not the sole motive. ARSI now offers us a common platform to share our experiences and also to keep abreast of advances in surgery so that they can be selectively used and modified for appropriate use. We desire to keep the windows of science open, but not be seduced by the sirens of expensive technology so vociferously promoted by the globalized medical market and' foreign experts'. It is heartening to see how many experts from other countries subscribe to our concept and have come to join hands with us. We welcome them and admire how they keep their vision of universal mankind alive amidst a sea of increasing irrelevance. To cull out the wheat from the chaff. Living in the rural setting we cannot but help appreciate the reality of our country and of our people; of their strengths and weaknesses and above all the socio-economic conditions and deprivation under which they survive against formidable odds.

It is not the traumatic sutures or the pulse oximeter that determines the quality of surgical results. This only increases cost and denies surgery to those who cannot afford it. The results of surgery have improved because of a better understanding of Wound healing and of anatomy and micro circulation and not because of antibiotics, antiseptics or traumatic sutures. Improvement in anesthetist is due to a better understanding of physiology and cellular metabolism added to the single most important function of the anesthetist which is continuous and careful observation of the patient's vital signs; not the monitors. Expensive monitors and intensive care units cannot replace intensive observation by the surgeon and the constant loving care of the nurse and the patient's own relatives whose physical as well as Psychological support is an important part of the healing process. The cost effectiveness and appropriateness of all procedures must match the pockets of the patient as well as his/her family; for the 'latest' and the 'best' is often be the enemy of the 'good'. Fortunately the experience of most members of ARSI demonstrates that the same surgery undertaken equally effectively by them is generally five to ten times cheaper than if the patient goes to the city; with little difference in the quality of the result. The care at the periphery is more personalized and humane even though without the urban frills. The savings in overhead costs such as transport of patients and relatives, their loss of wages, and other hidden expenses is considerable. Unlike the Westernized elite and middle class the rural patient has roots in his/her culture which also accepts unavoidable pain and suffering such as the aging process and acceptance of death with equanimity as a natural process; not demanding a pill or an operation for every ill or an intensive care unit. This must be understood and respected by those who treat these patients.

The originality of our members which contributes to the success of their surgery at such low cost needs to be carefully documented and the experiences exchanged. Many of you who do this as a routine, seldom appreciate its implications when used on a large scale. I never cease to be amazed as to how cheap is the effectiveness and cost of health and medical care, even in the private sector, when the commercializing effect of the market is eliminated or controlled.

The following are only a very few of the innumerable examples. The use of the EMO for anaesthesia, of the commercial oxygen cylinder available in any rural market place, the splints as well as fixation and traction devices for hand surgery devised by Dr. B.B. Joshi, emergency lighting, nylon shirting for hernia repair, soap and water treatment of burns, the Tobruk plaster and the banana leaf as a no cost biological non adherent dressing. Social cleanliness, the use of soap and water, debridement of wounds and gentle handling of tissues are more effective than antibiotics to cover the neglect of these principles of surgery .Costly Betadine and antibiotics cannot replace this. I believe that surgery can be even cheaper than what. we of ARSI practice at present, without sacrificing quality.

Most of our members enjoy a fairly comfortable life with the added job satisfaction that only care of the less privileged can provide. We do not have to raise charges under the guise of defensive medicine for fear of being sued under the Consumer Protection Act. For the occasional case we may obtain a cheaper insurance premium than charged in urban areas. The greatest remuneration that medicine can offer its practitioners has traditionally been the love and respect provided by society to what they have considered as being a 'noble profession'. This is now being denied to those who have embraced the material attraction of the city and the global market where love has been replaced by material goods.

For the next few years ARSI will face a certain amount of disapproval if not hostility from our own profession as it will be seen as a breakaway group not only from the parent surgical fraternity but also because it poses a threat by demonstrating how good surgery can be offered at such low cost; an anathema to the market forces that seek to dominate modern medicine.

We must also convince our professional colleagues that ARSI is not a specialty but a return to good basic medicine and surgery .Specialization to me is a necessary evil which often blinker's the broader vision of medicine and surgery. Our membership consists not merely of qualified surgeon but also from various other disciplines such as gynecology, anesthesia and even MBBS doctors who have been serving the basic surgical needs in places where no such facilities exist. It is a return to a state of sanity if the needs of the vast majority of our people have to be met and not only that of an urban minority; not sophistication for sophistication's sake!

There is no reason why our members should not participate in the meetings of other surgical associations like gynaecology or orthopaedics to gain knowledge which can be used for the larger 'cause of the many who do not have access to such specialist facilities. And yet I fear that the identity of ARSI should not be lost by holding 'joint' meetings for the convenience of some members. We welcome membership from all those who believe in the basic conviction of our Association that surgery is for the people and not people for surgery.

Those who state that surgery and Its techniques cannot be different In urban or rural areas are unaware of the entirely different socio-economic, cultural and many other differences In the problems as well as facilities of these two nations namely India and Bharat, that live cheek by jowl In the same subcontinent. Also the Ingenuity of Bharat which survives despite all handicaps.

The rapidity with which the carefully selected membership of our Association has expanded from all over the country is a measure of the need for such an organization. And yet I see forces that feel threatened and wish to deny the facilities of such surgery to the rural population under the guise of safety and legality. Is it justifiable to deny blood transfusion to those who live in rural areas under this guise and let them die legally or help them to survive illegally. This is a new dilemma created by vested interest and threatens to be the thin edge of the wedge. This will inevitably be followed by similar legal restrictions legislated by the government and courts at the behest of urbanized medical and surgical Associations like that of pathologists, radiologists, nurses, paramedicals and physiotherapists to safeguard and increase their empires. These associations, like other unions, seek to increase their membership and power by a display of excessive and unnecessary sophistication, rules and regulations to prevent what they consider inroads from others. They use the techniques of mystification, fear and scare mongering among the public. In this they are unconcerned about the denying of their knowledge to the majority of our people, especially those who live in rural areas, which to them is often a second rate country apart. This ever increasing exploitation by monopolizing knowledge and technology is a part of this market economy based on personal and professional aggrandizement under various garbs. We are well aware of its existence in our own profession clothed under the garb of specialization. Unfortunately the members of these associations working in elitist urban hospitals have an easier access to the ears of the lawmakers and rural associations like ours. The consequences of denying such knowledge and technology to the vast population of Bharat Is not their concern as citizens, even though they know the untoward effects. These are man made laws meant to serve man. Such unjust laws must be objected to and if necessary challenged if they go against the morals and ethics of our profession.

It is not that we wish to conduct our affairs in any manner we chose under the umbrella of Rural Surgery. We would like to have adequately trained staff for our varied requirements. We appreciate that under the prevailing circumstances we have no alternative but to train local personnel ourselves, except for doctors and nurses. Few of the staff who are presently trained in urban centres are prepared to live and work under the existing conditions of rural areas. Their urban training is unnecessarily, unnecessarily complicated and unsuitable for the multipurpose requirements of the smaller rural hospitals. The curriculum as well as the and values inculcated in urban training centres has little in common with rural requirements.

And yet we feel that it is necessary that those who work in rural hospitals must have the adequate basic knowledge and skills for their job requirements. The advent of large scale distance multimedia education in the local languages like that of the Indira Gandhi National Open University and the National Open School now makes it possible to provide appropriate training to local boys and girls suitable for our requirements and can provide them with a certificate to that effect. This would not only provide relevant education and jobs to a vast number of rural youth but would also help improve the quality of rural medicine and surgery. It would also meet legal requirements. The experience of ARSI in developing the Certificate Course for Rural Surgery has initiated this process and needs to be extended to paramedical and perimedical workers. This can also provide Continuous Education so lacking in our present system.

Our response to such unjust man made laws cannot be merely to pursue the matter in High Courts and Supreme Courts through Public Interest Litigation for which we have neither the time, legal know how or finances. Our job is to activate the people themselves to fight such injustice perpetrated on them without concern for those who have to suffer the consequences. The 73rd and 74th Constitutional Amendments, under which health is also a Panchayat subject, now provides the necessary power to the people to demand what is their lawful right. Panchayati Raj has been a slower but far superior power obtained by them through their vote as a result of universal adult franchise conferred to them at independence, rather than through a benevolent dictatorship as in China. It is the only true form of democracy. Those who can overthrow Central and State Governments can surely demand their constitutional rights of survival if they are made aware of these problems and their rights as equal citizens. It is they who are most concerned and interested in their own welfare and look up to us for knowledge, advice, and guidance to enable them to exert their power in matters of health. Knowledge and information is the key and our education gives us access to it, which they lack.

There is no reason why we cannot also play a larger role in our society by taking part in the overall improvement in the health and welfare of our community as also of the Block or Taluka. This is now feasible under Panchayati Raj where the people are increasingly involved in their own welfare. We can surely extend our activities beyond the confines of surgery. This would provide greater satisfaction and meaning to us, as well as also to the people, if we participate with the community and Panchayats at its various levels especially in the preventive and promotive aspects of health which covers most aspects of life. We are in a unique position to provide such knowledge and technology in a variety of ways appropriate to local needs. In this we would be participants in our country's development. Anew India can reemerge only from the villages of Bharat who we have neglected at our own peril. The present urban problems are a manifestation of this neglect.

Such participation and involvement in the local community would not only be a stimulating experience but would be the most effective way to counter the fear of the CPA which threatens our urban colleagues. It would also help to regain the love and respect that our profession has had in the past.

The demise of the cities and improved conditions of the taluka towns together with Panchayati Raj now offers the opportunity of a major shift of medical and surgical services from the urban to the rural areas. This shift will also have to be of a qualitative nature from over-Westernized and over-specialized surgery to basic surgery for all.
Together we can build a new India. Jai Bharat!