One evening, three years ago, 34-year-old D Raghavendra met with an accident as he was riding his two-wheeler in the city of Sindhanur, in northern Karnataka’s Raichur district. The father of two was rushed to the government hospital in the city, but was told that there were no doctors who could treat him. He was instructed to travel to the government hospital in the neighbouring district of Ballari, around 90 km away.
“It took us about two-and-a-half hours to get to the hospital in Ballari,” Raghavendra said. “There was some kind of strike at the hospital. They also said they didn’t have doctors who could treat my injury and they asked me to go to Bengaluru.”
Raghavendra got to Bengaluru at 6 am the day after his accident. He had been bleeding the whole way, he recalled.
In Bengaluru, doctors spent the first day performing a variety of scans and tests. “The next day, they amputated my leg,” he said. “They said there was no blood circulation in my legs and they could not save it.”
He still wonders if the procedure could have been avoided. “Sometimes I think maybe if I had the money and could afford to go to a private hospital, I may not have lost my leg,” Raghavendra said. “Even the doctors said that perhaps if I had arrived earlier, as soon as the accident happened, they may have been able to save my leg.”
Raghavendra is not alone. India saw two million amputations in 2019, according to one study, the only such global survey of the procedure that has been carried out. The study found that India had the highest burden of traumatic amputations among 204 countries and territories surveyed. (The study looked at the period between 1990 and 2019, and did not provide figures for other countries, such as China, which had the second-highest number of amputations.) Including past cases, India had a total number of 75.6 million cases of amputation.
On the surface, the reason for this is fairly simple: India has the highest number of road accidents in the world. A 2021 paper noted that road traffic accidents were the most common cause of traumatic amputations, “with 85.4% of patients having sustained road traffic injuries”.
However, many amputees in India have never been in a road accident. Many lost their limbs to foot ulcers caused by poor blood circulation, a condition often associated with diabetes, a growing health concern in India even among the poor.
This was the case with 67-year-old Nazeer Ahmed, from Bengaluru, who spray-painted cars for a living. Three years ago, when he noticed an ulcer on his leg, he went to the clinic near his home to have it checked. The doctor there told him it was a fungal infection and prescribed an ointment. Ahmed, who was diabetic, diligently applied the ointment to the wound, but it did not seem to improve. A few days later, he visited another small hospital. The prescriptions provided by the doctor there also did not help him.
Over the next two months, Ahmed visited around seven clinics and hospitals. “Each doctor gave us some tablets,” his son Imran said. “But nothing was helping. His ulcer kept getting bigger and bigger and he was losing sensation in the leg.”
Imran, who is an electrician, explained that in some hospitals, the family spent Rs 6,000 on treatment. Eventually, they were directed to the Bowring and Lady Curzon Medical College and Research Institute.
“When we arrived there, they looked at my father’s leg and told us that he would need to amputate three of his toes immediately,” his son said. “Six days later, they removed the dressing and checked and told us there was still no blood flow in his leg. The following day, they amputated his leg from above the knee.”
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The underlying cause of the high number of amputations in India, doctors say, are gaps in the healthcare system – specifically, the lack of adequate trauma centres for victims of road accidents such as Raghavendra, and vascular surgeons who can carry out procedures that restore blood flow to limbs for patients such as Ahmed.
“I got no help for over 12 hours, just lying in the ambulance bleeding,” Raghavendra said. “If there had been a good hospital near my hometown, I may not have been handicapped today.”
Murali, who is in charge of the KMYF Limb Centre in Bhagwan Mahaveer Jain Hospital in Bengaluru, echoed this contention. Each day, the centre sees between eight and 15 individuals seeking artificial limbs, he said, the majority of them from rural regions of the state and neighbouring states.
“We do get cases where people say they weren’t able to have their limbs saved because they went to a hospital that didn’t have enough doctors or resources,” he said.
Nazeer Ahmed’s case also illustrates this problem – despite living in an urban area, he was unable to get an immediate reference to the appropriate doctor. “It would have been good if the first doctor we went to had diagnosed what the problem was and referred us to the correct place,” his son said.
Dr Sidharth Viswanathan, a vascular and endovascular surgeon at Kochi’s Amrita Hospital, said that this was not an uncommon problem, and that many medical practitioners do not realise that foot ulcers or discoloration are caused by lack of blood flow. “Often patients are referred to specialists when it is already too late,” he said.
Viswanathan explained that many such patients need vascular procedures to restore blood flow to limbs. Instead, some doctors with inadequate training simply remove infected tissue until they find clear tissue, then dress up the wound and send the patient home.
“The patient will return with the foot black again and the doctors may amputate more and more, until they realise that it’s not the solution,” he said. “By the time they come to us, there will be multiple toe amputations and a majority of the foot is already gone. Then we try to save whatever little is left, but often it's too late.”
Viswanathan encountered this lack of proper training even in the early years of his own career. As a resident at a government hospital in Kerala, he said, he and his peers were given a small room to treat foot infections.
“We would only be asked to clean the wound and then crudely cut off all the unhealthy tissue,” he said. “The solution was to just keep cutting until the wound heals. Most patients were not offered an alternative.”
It is the poor who suffer the most from these flaws in the system. According to a 2021 paper that studied patients at a level-one trauma centre, of 3,047 trauma patients, 125 patients needed an amputation. “The majority belong to a poor socioeconomic background, warranting ongoing social support and psychological rehabilitation, maybe in the form of amputee clinics,” the paper noted.
This problem exists even in cases of amputations resulting from other causes. A 2006 paper that studied the urban-rural divide in the prevalence of “foot complications” among South Indian patients of diabetes found that an average of 8% of rural patients studied underwent amputations, while only 3% of urban patients underwent amputations.
Doctors that Scroll spoke to echoed this finding. Dr Shah Alam Khan, an orthopaedic surgeon from the All India Institute of Medical Sciences, Delhi, noted that often, the poor cannot access the right kind of care in time, to ensure that they get basic levels of treatment. “It is the people from poor and marginalised communities who suffer more due to less access to quality medical care,” Khan said.
The social dimension of the problem of amputations is evident from the fact that many poor patients try to save money by choosing short-term solutions such as partial tissue removal over longer-term ones such as vascular surgery.
But, Viswanathan explained, “The infection doesn’t heal unless a vascular procedure is done. The amount of money a patient spends on coming to the hospital repeatedly, getting a new dressing, on medications, plus the money they have to lose per day because they are missing work, all of this will eventually add up to how much a vascular procedure will cost.”
He estimated that a basic vascular surgery, without complications, could cost around Rs 1 lakh, and noted, “Patients can spend that money on surgery and avoid repeated doctor visits,” he said.
Some patients seek out even more crude treatments, such as traditional bone setting. A 2022 paper noted that they do so because, among other reasons, the setters are affordable and easily accessible, and because the patients fear hospitalisation and surgery. But many eventually end up at hospitals with complications.
“In cases of fracture, the bone setters often tie the bandage so tight that blood flow stops,” said Dr Madan Ballal, the director of the Sanjay Gandhi Institute of Trauma and Orthopedics, in Bengaluru. “Sometimes causing permanent disfigurement and damage.”
Scroll encountered such cases. At the KMYF Limb Centre, 30-year-old Rajesh V, who was grievously injured in an accident three months ago, was visiting to procure an artificial limb. After the accident, he had been immediately taken to a private hospital – in fact, at the time, he worked as a ward boy at the same hospital. However, his family decided that it would be too expensive for him to have a surgery done at the hospital, and so took him to a bone setter instead.
“That night his leg got very swollen,” his mother said. “When he was taken back to the bone setter, he said there was nothing he could do and asked us to take him to the hospital.”
Rajesh recounted that when they returned to the hospital, “the doctors scolded us and said that the bone setter had made the cast extremely tight which had stopped blood flow entirely. They said there was nothing they could do now and that I had to have my leg amputated.”
It is not only patients who make flawed decisions – often, Viswanathan noted, doctors fail to give the patients a reference to specialists. “They may tell the patient that there is no blood supply in the leg and just amputate above or below the knee, where there is adequate blood flow,” he said.
He explained that there was also a shortage of qualified specialists. “Vascular surgery is also a relatively new area of expertise,” he said. “So, smaller medical colleges and hospitals may not have specialists who can diagnose properly or provide care.”
Sometimes, even putting doctors through a short course or training programme can make a massive impact, said Dr Muralikrishna N, head of vascular surgery at the Sri Jayadeva Institute of Cardiovascular Sciences and Research in Bengaluru.
“We had a medical team from Hassan visit our hospital and learn about how to correctly diagnose patients who may have vascular problems,” he said. “A few months later, they told us that their amputation rates had come down by 95%.”
While the medical system places the poor at a severe disadvantage and leaves them more likely to undergo amputations, they also face far greater struggles after.
Before his accident, Raghavendra, who has two children, did road construction work for a living, earning Rs 1,000 per day. He met with the accident just three months after his second child was born, and hasn’t been able to work since. “I have two younger brothers who support my parents, my wife and our two small children,” he said.
Eager to get back to work, in mid-February, Raghavendra had travelled to Bengaluru to meet Murali, at the KMYF Limb Centre. It was his first visit to the centre, and he had travelled almost 450 km by bus from Sindhanur for it.
“I have tried to get a job, but all jobs demand physical movement and labour which I simply cannot do,” he said. “That’s why I am here now. Hopefully, if I get an artificial leg, I can start looking for jobs again.”
K Venkatesh, a 61-year-old native of Ballari who was visiting the Jayadeva Institute, was also struggling to manage his finances after his leg was amputated. As he sat in a wheelchair, waiting in a long queue to consult Muralikrishna’s team, he listed his expenses. “In all, I have already spent Rs 10,000,” he said. “On the train, the lodge, food and the scans I’ve been asked to take.”
Venkatesh was diagnosed with a heart disease around 14 months ago – he already suffered from diabetes at the time. He visited his son in Mumbai and consulted doctors at three different hospitals for treatment before undergoing an angioplasty. He believed that he had recovered, but when he returned home to Ballari four months ago, he started feeling numbness in his leg.
“When I went to the government hospital in Ballari, they told me that there was less blood flow in my leg and that I had gangrene,” Venkatesh said. Doctors told Venkatesh that four of his toes would need to be amputated. He underwent the procedure, but immediately after, they gave him more bad news – that his foot and tibia would need to be amputated. To his shock, soon after the surgery, the doctors told him that he needed to be amputated even further, above the knee.
Before the onset of his health problems, Venkatesh earned Rs 12,000 a month as a security guard for a private company. He has been unable to do this work after his amputation and he has no income, even as expenses mount.
“I have an SC and BPL certificate,” he said, referring to Scheduled Caste and Below Poverty Line certificates. “Yet I’m being charged for scans. Paying Rs 4,000 is a huge burden for me.”
The burden is higher because Venkatesh uses crutches and thus, cannot travel from Ballari to Bengaluru alone – instead, he brings along a relative every time he travels for a check-up. “I have to pay for two people's accommodation and food every time I travel,” he said.
This also means that his relative has to forgo his daily wages to accompany Venkatesh each time. Venkatesh has been borrowing money to manage these expenses and stay afloat.
He is hopeful that procuring a prosthetic limb will ease his troubles. “If I can get a prosthetic leg, I will go back to working as a security guard,” Venkatesh said.
The problem of a lack of medical infrastructure in the country is reflected in the poor outcomes of amputation surgeries in India – a 2022 study of a level one trauma centre found that 28.7% of patients who had undergone amputation at the centre needed “stump revision” surgeries to correct problems they faced afterwards. This rate, it noted, “is somewhat higher than reports from other developing countries in Asia and Africa”.
The paper found that this difference in rates could be attributed to “firstly, a heavy patient load and limited availability of operating rooms”. It noted that most amputations were performed at “odd hours” by registrars, who are doctors who have obtained a degree and are in training. Further, “delays in surgery happen due to factors like the late presentation to hospitals, polytrauma requiring resuscitation, and in-hospital delays” owing to factors such as “limited operation theatre space”, it stated.
Khan said that most tertiary centres do not have specialists or facilities to ensure that patients’ limbs can be saved. “Many tertiary care centres also don’t have a proper trauma centre,” he said
For example, according to a 2019 news report, Karnataka had only one dedicated government trauma centre, which is linked to the Bangalore Medical College and Research Institute, located on the premises of the Victoria Hospital. Three more were in the process of being set up.
The Comptroller and Auditor General of India’s 2021 performance report on the Karnataka State Road Safety Authority also pointed out the lack of infrastructure in the state for treating trauma cases.
“The Health Department was not allocated funds to improve the medical infrastructure including establishment of highway trauma centres,” the report said. “Records furnished by the District Health and Family Welfare Officer revealed that there was no initiative till March 2021 to establish” trauma centres in 22 districts.
Muralikrishna argued that the government had to invest in creating infrastructure for super speciality care “so doctors can practise and patients don’t have to travel so much to get quality care”.
Further, Khan said, the country lacked sufficient infrastructure along highways, a major lacuna given that the majority of patients who needed amputations had been in road accidents.
In 2019, the union government announced that it was launching a scheme to set up trauma centres along national highways. The scheme envisioned a trauma centre every 100 km on the highways.
But Muralikrishna pointed out that while this goal had been met in some states, such as Tamil Nadu, in other states, progress had been far more limited. This, in turn, places a greater burden on other hospitals and their operation theatres.
Meanwhile, for those who undergo amputations, the implications are devastating. Research has shown that those who undergo the procedure do not only suffer disability but also have reduced life expectancy.
In fact, Viswanathan pointed out that life expectancy in patients after amputation was lower than life expectancy in patients who are diagnosed with cancer. A 2020 paper that studied mortality rates after minor amputation among patients with diabetes or peripheral vascular disease, or both, found that “the survival of patients who had undergone a minor LEA [lower extremity amputation] has been worse than that for patients with many common cancers, such as Hodgkin disease and breast, oropharynx, kidney, prostate, and, even, colon cancer”.
Muralikrishna also pointed out that research had shown that 40% of amputees survive for only two years after their amputations. One paper noted that “mortality following amputation ranges from 13% to 40% at 1 year, 35% to 65% at 3 years, and 39% to 80% at 5 years – worse than for most malignancies”.
Viswanathan explained that this was because an individual’s mobility is “significantly reduced” after an amputation. “Whatever activity the person was doing to keep their cardiac and vascular system healthy stops,” he said. “So if you have a disease and then have an amputation, life expectancy is reduced.”
Thus, he argued that except in completely unavoidable cases, “we must understand that things will not automatically improve after an amputation, the patient actually deteriorates”.
