India has a severe lack of surgical resources. Among first level referral hospitals across the country, 39% of primary health centres did not have an operating room, 19% of district hospitals did not have a surgeon, 83% did not have an anaesthetist and 91% did not have a blood storage facility, according to a paper on the state of healthcare in South Asia released by The BMJ on Wednesday. None of the medical facilities analysed in the paper met the criteria of well-resourced hospitals. Urban areas do better in access to surgical facilities than rural areas but only marginally.
The unmet need for surgery across south Asia has has harmful consequences. A study from Pakistan estimated that there were 187 deaths per 1,00,000 persons per year from acute surgical illnesses. This is more than the deaths from infectious diseases, including tuberculosis, HIV/AIDS, diarrhoeal disease, and childhood infections.
A study from 2015 showed that in India people living in remote areas of India were often late in accessing care for routine emergencies and after road traffic accidents, which led to a large number of preventable deaths.
Dr Sanjay Nagral, a gastroenterological surgeon at Jaslok Hospital in Mumbai and one of the authors of the paper spoke to Scroll.in about the inequitable and inaccessible surgical care in India despite increased specialisation and technological advances. Here are excerpts from that conversation.
What is the extent of access to surgery and how good are surgical outcomes in south east Asia?
We don’t even know the number of operations performed. Access is difficult to define. What we know are that diseases that should to treated through surgery effectively, do not get treated.
A good example is the Million Death Study quoted in our paper for abdominal or intestinal perforations. They estimated 50,000 people died in india in 2010 who could not access hospitals. They are often often spontaneous perforations, not just trauma cases. These people should never die. So, we have indirect evidence that access is a big problem.
It is a strange combination that we are seeing. On the one hand you have an access problem both in rural areas but even in urban areas, where emergencies are delayed. We hear stories from Mumbai where accident victims are going in ambulances from one hospital to another and are denied beds. On the other hand we have lot of advanced surgeries.
The rich have sorted it out for themselves. There is huge technology available for people who are willing to pay. If you reach a posh big hospital and want a liver transplant, you may get it.
You mentioned trauma as being one of the biggest issues when it comes to lack of access to surgeries.
If you have an accident four hours from Bombay, you will be really lucky to get immediate surgical treatment. It depends on who takes you where. If you are conscious, you can say take me to a certain hospital. We regularly treat patients who three hours prior had accidents outside Mumbai and have not even got a basic fluid intravenous line. There is huge deficit of care in emergency surgeries and most glaring is in accident and trauma.
First of all, we have an epidemic of trauma and are unable to deliver care but even in the seventh hour. Second, you have no formal referral systems. There is complete failure in trauma care.
Is it not better to improve our health systems to address problems of access to surgery?Poor healthcare is the reality. Given that, there is a little emphasis on curative surgical care. Traditionally the government has looked at maternal and child health and family planning as its main function. They have left tertiary care open to the market.
But what happens to someone who needs blood? These guys are left to the wolves. The health care failure is obvious but, even in that, surgery is looked at as esoteric.
Your paper says that mass medical camps, which are a South Asian phenomenon, are not an answer to address unmet demands for surgery.
I think that, in principle, it is a bad idea. It started in India with cataract surgery camps. Cataract surgery is a simple surgery. Then it began to be seen as a strategy and was used for tubectomy.
These camps, which we have said is a South Asian concept, are a performative sight. It is a political initiative where someone gains brownie points. Excessive emphasis on camps is a problem and the authorities are not going to the root of the problem. This is exactly how all public health issues are addressed – looking at a temporary solutions that are symbolic.
Often people say that voluntary groups can fill unmet needs. Hospital such as Aga Khan University in Pakistan and Christian Medical College in Vellore are doing a good job. But that cannot be a model for a country. These are all flashes in a pan. Social voluntary organisations cannot be replacement for solid state structure.
Do you feel that surgeons are needed at the district level?
Surgeons being surgeons – in this I include myself – are highly specialised and highly skilled. We are not going to serve at sub-district level. Training doctors from ayurveda or homeopathy in basic surgery is a good strategy. They are more likely to go to under-served areas as opposed to super specialist surgeons.
The first five steps of trauma care in many parts of the world are done by paramedics. In North Kerala, a network called Angel has trained people from the community as paramedics. It is a one-year course. They are the ones who manage ambulances and it is turning out very well. We have to empower others. I spoke to a 108 ambulance doctor who is a non-MBBS doctor who says he is not trained to do anything but accompany the patient. So empower them, train them.
We have to train people in basic surgery like putting in a breathing tube or suture wounds to stop bleeding. These surgeries can be life saving. It is actually an extension of first aid. Other countries have done it, so why can’t we?