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  Presidential Address
Delivered at Xth, National Conference of the Association of Rural Surgeons of India at VAPI, Gujarat, November, 2002

Sitanath De President ARSI
Banshree Clinic Jhargram WB

  It is indeed an honour and a privilage to address you as President of the Association of Rural Surgeons of India, at this, 10th National conference of our organization. A.R.S.I. aims to improve rural surgery and, as a consequence, the surgical care in rural India. It is therefore very appropriate that we find ourselves assembled here at Vapi, in the heartland of Bapuji's Gujarat. Perhaps our discussions and exchange of surgical ideas may also contribute in some way, however, modestly, to Bapuji's dream for the upliftment of Rural India.

While all of us are aware of the need to improve the quality, and quantity, of surgical care delivered to the 70% of the population living in the rural area, who are frequently denied even the most basic amenities of life. Do we truly understand the enormity of the task, we in our association are attempting? I am thinking about, the city surgeons, the super specialists, taking magnificent strides in technology to bring India to the forefront of modern surgery. We admire you and are justly proud of your achievements. We welcome those of you who have made the efforts to come and join our deliberations today. But I ask you all, are you truly, aware of nature of the "disease" we are trying to treat ? I mean, of course the disease is poverty. Poverty is persistent and wide spread that we cannot even dream of treating the patient with the barrage of sophisticated 'hi-tech' procedures that modern surgery has to offer. Let me illustrate my point. In my own area of south West Bengal, the local population is made up largely of agricultural workers, on daily wages. According to the 1991 Census, the local per-capita income was found to be Rs. 325 per month. The figures from the 2001 Census are not yet available but have been estimated at not more than Rs. 1000 per month. This amount is expected to look after a family of at least four dependents. In these circumstances, I feel ashamed to ask for even the simplest diagnostic test. Should I leave these patients to the mercy of the local "quacks"? We in the A.R.S.I. are determined to do our utmost to bring effective, economical surgical care within the reach of rural India. But my friends, so far we have only managed to grasp the nature of the diseases. In our efforts to remedy the disease we have done no more than to make the first skin incision ! In order to effect a cure it is necessary to make a deep incision and eradicate the cause of the disease. The question remains how shall we make that deep incision?

Until recently, there was a fairly reasonable system of delivery of Rural Surgical care. 60% of all surgical needs were met by the private sector, and the remaining 40% by the National/State Surgical Health Services.

This system is on the verge of collapse. The state health services have been compelled to charge the under privilaged section of society, in order to raise revenue to pay back the huge loan they have taken from the World Bank. Those below the poverty line are supposed to be exempted from health charges, on the production of 'a Certificate of Poverty". However, since such certificates are obtainable from the nearest footpath, this attempt to gather revenue has merely opened the floodgate to wide-spread. The result is that those who had access to free medical care from the State Health Service are now forced to pay for the treatment they receive.

The private sector, providing 60% of all surgical needs in the rural area, is also under pressure. Those of us who have battled for years to establish a small surgical clinic, where it is really needed, in the rural area, are painfully aware of the enormous difficulties involved. The physical struggle to create a modest building where none of the basic amenities of water, power and transport are available, the professional and social isolation and the pressing problem of providing adequate education for his children are well known. Above all, the lack of financial security for the surgeon and the extreme poverty of his patients makes even the thought of setting up a surgical clinic in the rural area, a daunting project. It is no wonder then that the young surgeon of today quickly abandons any idealistic dream of serving the rural poor and soon succumbs to the blandishments of modern "commercial" surgery and the sophistication and security of city life.

But my friends are we to abandon the patient on the operating table itself ? He is still moribundly sick and any delay in treatment could be fatal! Such severe disease requires drastic measures and today I would like to prescribe, and strongly advocate, two lines of urgently required treatment.

As a first line of action I would like to see a complete review and adjustment of the Consumer Protection Act and the Clinical Establishment Act as they stand in relation to small surgical clinics in the rural area. On the face of it, the Consumer Protection Act, which equates medical care service with industry, is a progressive move intended to give people their rights- urban and rural medical facilities should be equally available to all. This is a cruel joke for thousands of rural patients waiting patiently for dialysis and renal transplant in villages which are cut off from the world every rainy season and where electricity does not flicker even for an hour. Stories about untimely death in rural health-care clinics make a big splash in the dailies. But sadly the fact that thousands of life-saving operations which are being performed all over the rural areas, without even the minimum facilities being available, and under severe financial restrain are totally ignored.

The brave surgeons who perform such operations are harassed by questions in the consumer court such as "Why didn't you do the Hb?" "Why didn't you do kidney profile test?" "Why did you employ unqualified paramedics to give injections?" The decision to bring Rural Medical Care within the C.P.A. has been made by people who have no concept of the reality of how the 70% of rural population of India receive their health care. As it stands, the C.P.A. is a deterrent to any young surgeon, planning to set up a modest rural clinic of his own. He will no longer have the courage to attend even the simplest procedure at home. Instead of taking the necessary curative measures himself, he will be desperate to shift the onus of responsibility to a sophisticated nursing home in a city centre. The patient who has no means for this city treatment will be abandoned, and the doctors dream of being a 'rural surgeon' will be lost forever. To prevent the loss of such desperately needed young surgeons to the rural area, it is essential to remove the elements of fear and apprehension from the mind of the rural surgeon. The law makers need to make a realistic reassessment of the rural scenario and make some practical adjustments or changes in the C.P.A. Rural clinics should be removed from the C.P.A. and only 'negligence' should be a point of criticism against the medical practitioner. This would immediately reverse the trend of referring patients to urban centres unnecessarily and rural practice would be allowed to continue it's service unhindered.

The Clinical Establishment Act also needs to be reviewed in relation to small rural surgical clinics. It is quite illogical that the tiny, frequently single-handed run rural clinics which provide at least 60% of the immediate surgical needs of the rural population of India, should be equated with full Nursing Homes of 25 or more beds. It is of course praiseworthy that an attempt is being made to ensure acceptable medical standards, but the small-scale rural surgical clinics are a special category. They require a set of 'guide lines' which takes into consideration the fact that the essential 'basic amenities' of Gas and Oxygen supply, running water and a regular power supply. Simply do not exist in the area in which the clinic is most desperately required. Instead of crushing small surgical clinics out of existence, by heavy handed regulations. some sensitive and imaginative assistance is required from the government. Interest free loans could be made available to young doctors prepared to set up a surgical clinic in the rural area, to provide basic minimum needs. Special help could be arranged to provide Oxygen and anaesthetic gas to doctors in remote areas, on a regular basis at controlled rates. Doctors could be assisted to invest in more sophisticated diagnostic equipment and steps could be taken to ensure that medical companies which provide such equipment, are also legally bound to provide adequate servicing on site in the rural area.

Financial incentives could be given to nurses and paramedical workers prepared to work in rural areas. Finally. educational opportunities should be provided to enable the rural surgeon to attend seminars etc. and for his children to receive adequate education which is frequently not available in the rural area. Before any 'minimum requirements for nursing-home registration' regulations are passed, it is essential that the particular problems of small-scale rural surgical clinics are carefully considered and steps are taken to ensure that they are not stifled out of existence by over-zealous and myopic legislation.

A review of the C.P.A. and the clinical establishment act may be enough to save the small-scale rural surgical clinics but where are the surgeons who are brave enough, and confident enough to overcome all obstacles and settle into a rural practice? Increasingly, the trend of today, is for the budding surgeon to launch into his post-graduate specialty while the ink on his M,B.B.S papers is still wet. He has had no experience at all of life outside, the 'security', and I the infrastructure his teaching hospital provides.

For my second course of prescribed treatment for the ailing "patient", Rural Surgical Care in India, I would call for a complete rethinking on our present system of post-graduate surgical training. It is high time that a drastic change should be made to the current system of postgraduate surgical training, which closely adheres to its Western Model. It encourages early specialization in restricted fields and at best can serve only a small fraction of the surgical needs of the country. Specialists have a tendency to blossom into "Super Specialists' and when they cannot find scope for their specialty in India, they flock to 'Centers of excellence' in other countries, and India looses a precious resource. The need of today is for a thoroughly competent general surgeon able to tackle whatever challenges he faces, often in extremely difficult circumstances without the support of a full-scale hospital behind him.

To create such a surgeon, A.R.S.I. Envisages introducing a fully comprehensive "M.S. in Rural surgery" as another option in the entrance counselling for post-graduate surgical training. At completion of training, the surgeon would be competent in the basic operations of all specialties, with a course in preventive and social medicine added to the curriculum. There should be residential, practical training in surgery, Gynaecology, Midwifery, Orthopaedics and a few months each in Thoracic surgery, Neurosurgery, Paediatric surgery and Anaesthesia, with associated exposure in an I.C. Unit. It is only this type of multi-disciplinary residential training that will give the rural surgeon enough confidence to tackle the diverse surgical problems he will encounter in practice.

"Importing" a specialist in a specific field into the rural area is unsatisfactory, as they tend to confine themselves only to their specialty. For example, a M.S. Gynaecologist will refuse to have anything to do with a case of appendicitis or perforated D.U. in the absence of a general surgeon, and will invariably refer the case to an urban centre. Similarly, a M.S. general surgeon will refuse to do a Caesarean Section in the absence of a gynaecologist who happens to be away attending a seminar or a conference. This happens frequently and the patient is passed from centre to centre like a ping-pong ball. A mastership in rural surgery, with multi-disciplinary training, would prevent countless such refusals and earn the heartfelt appreciation of the rural patient.

It is not possible to layout all the details of this concept in the limited time available here. But I would like to mention one important feature of the envisaged course. District and sub-divisional hospitals should be utilized to provide practical "hands on" experience in the different branches of surgery. These hospitals are a gold-mine of experience in their wealth of clinical material and would help develop a realistic approach to the problems, which are encountered in rural surgical practice. Advanced technology may be lacking in many cases, but clinical skills are at a premium here. Moreover the student will be exposed to the economic conditions of the patients and learn how to temper his approach accordingly.

Such a radical approach to post-graduate training would obviously require the imaginative co-operation of a number of august official bodies if it is ever to gain acceptance. However, granted such acceptance, the A.R.S.I. could help the medical administration to formulate a full and intensive practical training leading to the most desirable and most needed degree of M.S. in Rural surgery. I hope that it may happen!

In case, I have sounded discouraging and pessimistic about the future of rural surgical care in India, let me reassure you that this is far from being the case. We are still a young organisation, only 10 years old, the next 10 years should prove a challenging assignment to all of you with a spirit of adventure and the will to succeed against all odds.

Drawing conclusion based on my own experience, after 33 years in a small single-handed practice, I would say that a well-founded group practice would alleviate many of the problems I have encountered along the way. I believe the friendship and character development which would invariably grow amongst classmates on the M.S. (Rural Surgery) outlined above, would also facilitate the setting up of a compatible group practice at a later stage.

I would like to see an extensive increase in the reach of our organisation. There are still many surgeons working in isolation in remote places who are unaware of our existence and unable to benefit from the particular fellowship we offer each other at such occasions as today. It is essential that every encouragement be given to these young surgeons because India is facing an acute short-fall of surgeons, willing and competent to work in the rural area. It would be a practical and reliable contribution to our cause if A.R.S.I. was to organize a full profile of all surgeons working in the rural area today, so that a realistic appraisal may be made of the number of surgeons, the rural areas of India will require in the next 10 years.

In this era of super specialisation, there seems to be a huge gulf between the professional academics with their fascination for 'hi-tech' diagnostics and minimum invasive surgery, and contemporary Indian Rural Surgeons. The "Whizz-kids" of modem surgery in India remain enclosed within their own sophisticatede circle. Not for them the problems of how to obtain a histopathologist's report or fill an oxygen cylinder, while working in a remote rural area, and yet the aim of all of us is same, how to provide the most effective and economical surgical care to our patients. It is for us in the rural area to reach out to our super specialists and help them become aware of the reality of surgical needs in the rural area. Through our news letter we must involve ourselves in debate and seek out an interchange of views with our specialists, on the vital contemporary issues, which concern all of us. I believe that the concerted efforts of our organisation can lure the academics from their ivory tower and open their eyes to the needs of surgical care in rural India.

I am proud that A.R.S.I. is no longer a 'fringe' organisation but is a fully established association, recognised at home and abroad. There are many friends of our cause who have helped to nourish our association over it's first 10 years. We have grown from strength to strength with the support of our founder members, the late Dr. Sushila Nayar, Dr. Balu Sankaran, Dr. N.H. Antia and Dr. Tongaonkar. I am indebted to all the members of our Governing Council, not least, to our secretary Dr. S.Shivade, who has sacrificed his rare free time to keep our organisation running.

Let me remind you all that, although the recovery path may be stormy, the "Patient" -Rural Surgical Care in India- is alive and making reasonable progress !

And, on this cheering note, I would to conclude my remarks by sharing with you written by our revered Rabindranath Tagore, loosely translated by me:

Play thy tune in me,
With the same tune you play in the morning light
Play Thy tune in me.
Play Thy tune in me
With the same tune that you filled with music, a lost language
The tune that you played on the “life-flute” of a new-born child
The tune that you played on the smile, on the mother's adoring face.
Play Thy tune in me.
Clothe me with the same garment
That thou has clothed the dust of the earth, As the “Sandhya Malati” clothes itself With its own sweet fragrance.
Clothe me with the garments
Which make me forget “self” with joy.