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Presidential address

Dr. J. K. Banerjee
(On the occasion of Inaugural function of 15th National Conference of ARSI)


It is a great honour for me to be able to stand here before you as president of A.R.S.I. to deliver this address this evening. Maharashtra has given our Association the largest contingent of members and also the highest amount of activity. My salutations to the state for this. And my salutations to Anna Hazareji. Sir, I have browsed through your biography and seen a bit of your wonderful work at Ralegan Siddhi. Let me assure you that the person, who stimulated you to become a karmayogi, is the same who stimulated many of us to become rural surgeons today, the person who professed, "They alone live, who live for others. The rest are more dead than alive." (Swami Vivekananda)

Having been a founder member of ARSI, and having attended all the conferences of ARSI till today, across the country, I have grown as a human being. I have transcended the telescopic vision of a technocrat surgeon. I have realized that science, if studied in isolation, dehumanizes a person. I have realized the famous saying of Mahatma Gandhi that science without humanity is one of the seven deadly sins.

During these years of ARSI activity, I have seen rural surgeons practicing science WITH humanity. Today, five billion out of the total six billion population of the world either have no access or cannot afford the luxury of high-tech surgical or medical care. I have seen rural surgeons reaching out to this category of people through managerial and technological innovations, using their power of discrimination and judgment, and delivering appropriate care often facing scorn of the so called upper class and risking the breaking of unjust laws.

Knowledge or gyan in Bharatiya languages has three dimensions. The first dimension is Paroksha gyan. I learn from books, lectures etc. The second is Pratyaksha gyan. I learn with my own senses through practice. And when I learn through feelings, it is called Aparoksha gyan or Aparoksha anubhuti. Human learning towards its own evolution and ultimate goal is incomplete without the combination of all the three elements. I learn from books etc. how to do an Appendicectomy is Paroksha gyan. I learn by performing the operation is Pratyaksha gyan. And I perform it within a minimum infrastructure, investigations, and at the doorstep of the rural poor, out of a feeling or anubhuti for him, using clinical judgment more than laboratory tests thus making it affordable to them is application of Aparoksha gyan.

Application and benefit to humanity of any scientific knowledge system is incomplete without the use of all these three elements equally, and, according to someone like our father of the nation, a deadly sin.

We today practically see the impact of this type of unbridled and senseless scientific development, without the application of Aparoksha gyan, on human society. Increased human greed, excessive consumerism and dehumanization, devastating climate change leading to a forecast that cockroaches who are more radio resistant, will replace humans in future on this earth, revolt of societies against self appointed policing with the power of the gun. Little they realize that it is they who are taking the world towards its destruction as slaves of so called scientific development sans humanity. And the impact on health care of this type of development is of prime concern to us today in this forum.

The concept of rural surgery has grown from what it was when we first started the movement in a consolidated way. Initially it was a struggle to establish our identity as specialists in delivering multidisciplinary surgical services with limited resources to impoverished communities. Having won this crucial battle with Dr. Prabhu’s leadership, next was to establish wider and wider network with rural practitioners to learn ourselves and improve our quality of care - innovations and conferences, transcending the bureaucratic barriers of degrees and qualifications, invoking the spirit of Aparoksha Anubhuti into our professional practice. We made the pendulum of our professional practice swing from 'I' the great super specialist to "in the service of thou my patient". We threw the words "gold standard" and "state of the art" management promoted and dictated by the western health care industry into the gutter.

Albeit we are not against bringing in high-tech surgery to impoverished societies. But priority is on technologies economically sustainable and accessible by them. Technology flows from countries which have a percapita GNP of 30,000 to 50,000 US dollars. And ours is a meager 700US dollar. And then, 20% of the upper crust population swallows 80% of the countries resources with glaring discrepancies. Today for instance the richest man of the world is from India while farmers commit suicides unable to repay loans and children die due to malnutrition in rural areas. And 25,000 landless tribal had to march to Delhi the other day, to remind our economic pundits who wield power, to do land reforms so that they may survive in their motherland with a simple shelter on their head and two simple meals a day. Such is the impact of western form of development on our society today.

Coming back to the arena of health care, the movement of rural surgery has been quite successful in giving a twist to this form of inhuman development. We thus have earned enormous sympathy from the people and from some professorial surgeons. Membership strength is increasing everyday bringing in more and more of those professionals who have the eyes to see through the veil of industrial pressure and greed, who have imbibed the anubhuti component of education, who have developed the power of discrimination and the faculty of innovation. And it is because of sympathy from the understanding professors like Balu Sankaran, Dr. N. H. Antia, Dr. V. K. Mehta, Dr. R. Narang from inside that we have grown and stabilized. And support from outside of people like Professor Sood, Prof.Jena, Prof. Rajasekaran and Prof.Shyamprasad (now an insider) that the DNB course has come into being, more of which we will discuss tomorrow. And it is the strong willed professionals who have succeeded in taking it to an international level through the kind support of the German Society of Tropical Surgery (DTC), the Dutch working group of Tropical surgery. We now have networked with friends with similar problems and thoughts from eight countries of East Africa, Nigeria and Uganda and had started the ambitious I.F.R.S. Proof of the pudding is in its eating. The popularity of the concept shows its importance in the present day world of health care, and I venture to say that, friends, if we are able to steer our ship properly, rural surgery will be the biggest and most important superspeciality in the 21st century. And humanity will bless us for doing so. Now what is the course for the ship and how do we steer it.

The first thing we have to do is not to sit back and pat ourselves on our backs. Let us sit up straight. Let us start to learn from history and based on this learning, set our future course of steering the ship. What do we learn from the last sixty years history of healthcare development of independent India. Starting from the Bhore Committee report`s implementation, setting up the hierarchy of the health care administrative setups of the different states and the centre, and finally ending up in linear programmes. All of which failed to yield expected results in the long run. All of them, including the health components of the five year plans. And then jargons, comprehensive health care, primary health care health for all by 2000AD and so on. And in spite of all this, 400 million people in our country have no access to what the WHO terms as essential health care today. And finally, in a desperate attempt to tackle, the government, with opening up of the economy, is promoting privatization and corporatization of health care. And while 80% of our population is in villages and periurban slums, 80% of our hospitals are in large cities.

Albeit, against this dismal background, of the government`s efforts and policy, we see some bright stars. Rajnikant and Mabelle Arolle`s health care project, The Desai`s Jhagadia project, Dr. Bang`s Medico friends circle project, Dr. Sudarshan`s tribal healthcare project, and in recent times, those of Lalitha and Regi George, Ravi Tongaonkar, Balakrishna Patel and so on. Also the number of Christian missionary hospitals in rural areas and the Hindu missionary ones like those of the Ramakrishna Mission. These bright stars are all voluntary organizations where we find professionals with Aparoksha Anubhuti serving the masses. The same is the scene in African countries, to the best of my knowledge. And this is our learning from history.

To complete this learning, let us now look at the western world. In the US, few years back, the population without health insurance was 40million out of a total of 330million. Today, this population has increased to 60million while the total population remains nearly the same. Unable to provide services due to increasing costs, reforms in medical insurance policies, managed healthcare, HMOs and so on. The insurance companies have become more powerful and often dictate the management policies. And in March this year, the J.A.M.A. dedicated a whole issue on how to contain costs. And they came to the conclusion that the profession as a whole must unite in driving reforms away from cost cutting and short term fiscal competitions to starting catering to the patient`s needs. And in Europe, a strong

European Society of medical decision making is performing the same function. Technology assessment, evidence based medicine, outcome analysis and so on.

What is our final learning from all this. That time is ripe in India to consolidate the voluntary effort in health care. Not to depend on the Government. Let the government do what they are doing. All that is very good. But voluntary effort by health professionals has to be and must be strengthened. And the Association of Rural Surgeons of India is the only organization in our country which has already taken a step in this direction.

We have to consolidate further. And for that, two things are very important. First, we have to imbibe the spirit of rural surgeon ourselves. All of us will have to become, as Prof.Shyamprasad says, role models. "Not I but thou my patient". For every small and big activity we must be able to take the right step in the right direction in our day to day practice. And second, we have to be able to induct the younger generation to follow our footsteps. During the last few years, we at the Rural Medicare Centre have come across many young well meaning doctors who are fed up with the corruptions prevalent in our day to day practice. We have to be able to induct them into our way of practice. The DNB courses in rural surgery do contain a fair amount of this type of what we may call as value education with appropriate technology. Our association will have to make all efforts to provide support to this postgraduate course of the National Board. Create as many rural surgeons as possible in future years to come. We will also have to request the Government to provide financial support in the form of soft loans to those doctors who train and qualify through this course to setup small hospitals in the countryside. Something like a Grameen swasthya yojana programme under the National rural health mission.

Thus it is only through proper education and setting examples that we can induce the younger generation to provide health service in rural areas. Forcible posting by the Govt. will have a disastrous effect. First they will develop an antipathy to rural practice. And secondly, with little clinical acumen and with meager resources available there, they will not be able to do justice to the patient. If someone has to be forced to serve in rural hospitals, it should be the money minting corporate specialists of the city rather than the fresh graduate say for a month or two a year by rotation.

Friends, let our association therefore not rest but gear up to face the new responsibility of delivering appropriate health care to the entire population of the nation. We have to make our own plans for doing so. Let me assure you no foreign professor is going to come and do it for us, neither any international collaborations. We will have to do it ourselves, and with voluntary effort. To achieve this, we need not be a large organization, but an organization of strong willed people. Let us be like the Pandavas of the Mahabharata, who won the war with a much smaller army than the Kauravas. And I pray to God, may He help us in doing so.

Dr. J.K. Banerjee,
President, ARSI