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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, FRCS, FACS (Hon.)
Presidential address delivered at the VIth National Conference of
ARSI at Dondaicha, Dhule District, Maharashtra, on 13th November
1998. |
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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!
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