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Tales of a small town surgeon in India: the case for global health investment on essential surgery

Dr A works as a surgeon in a small town of India. Like any other small town doctor, he has settled for a practice here because of the affinity and close proximity to his home. Building up from the scratch, Dr A has slowly set-up an infrastructure that provides the best possible quality and affordable healthcare to patients from surrounding rural areas who can’t afford highly expensive private hospitals or far-off government hospitals.

Ankit Raj
Ankit Raj

Dr A juggles between multiple roles of surgeon, physician, administrator, treasurer and public health expert, often operating as a one-person medical team. While he still enjoys his profession, the lack of a ‘team’, as many doctors would agree, makes the job a daily-struggle and gruesome. Most of the support-staff hired in these clinics and hospitals are highly untrained and unskilled. For the lack of any better alternatives, doctors have to be content with this unfortunate setting. Often, this results in a team that lacks skills, discipline, experience and attitude to perform even regular procedures, leave alone highly complex surgeries. When one of the imaging machines malfunctioned in the middle of an operation, he had to wait almost a week for a technician to arrive from the state capital, and the surgery had to be continued blindly with archaic methods. In another instance, he had to use a manual orthopaedic drill, when the automatic drill stopped functioning in the middle of another crucial operation. Lack of technical support, unskilled staff and frequent power-cuts make this a usual occurrence. Inevitably quality of care and clinical outcomes are sub-optimal.

An anaesthetist is the captain of the surgical ship, especially when things go wrong. With only two anaesthetists in the town, there is a fierce scramble for his dates by orthopaedists, surgeons and obstetricians alike. Such issues add up to the stress of doctors like Dr A! Timely, affordable access to screened blood products is essential for the delivery of quality surgical care. Most of the time blood products are scarce and even if available the improper and neglected maintenance of blood banks(1) is a major cause of worry.

Challenges of chronic poverty limit the access to surgical care(2). The out-of-pocket payment of hospital fees, supplies and medications demands the surgical care to be extremely affordable, often adequately provided by doctors. The cultural belief and the general mistrust of healthcare only add up to the challenges being faced by the healthcare providers in small towns.

The seemingly disinterested Dr A is also a part of a larger problem of burnout among doctors. Without any recreational facilities and dearth of whatsoever social life, numerous surgeons from smaller towns are a victim of burnout-associated symptoms such as emotional exhaustion, dissatisfaction and physical weariness. This has led to depersonalization, decline of empathy and reduced personal and professional satisfaction. The cause can be traced to widely varying factors such as overwhelming workload, poor specialist-patient ratio, deficiency of recreational facilities and insufficient support from medical organizations such as Indian Medical Association (IMA). The IMA facilities in small towns have no provisions for recreational opportunities and CMEs and workshops are rare.

Medicine is a tough job no matter where you live, but it’s even more complicated when there is no formidable support system. Specialists like Dr A continue to provide essential and specialized surgical care in rural areas and small towns without getting much recognition. Globally, health surgery has shed the tag of the ‘neglected stepchild’ of global health and is now being recognized as an ‘indivisible, indispensable part of healthcare’ and several transnational initiatives(2) such as The Lancet Commission on Global Surgery (LCoGS) and the WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) have been initiated. Timely and affordable access to essential surgical care is the key to equitable healthcare delivery in underdeveloped regions of the world. Yet the challenges faced by the surgical care providers in low resource settings and how they overcome these challenges to provide care to impoverished patients have hardly been understood. It is time that we recognize and value surgeons like Dr A, and also build up our health systems in a manner that they can function optimally. Universal health coverage includes essential and safer surgery and anaesthesia and it is time that investments are made in this direction.

1. Jenny, Hillary E et al. “Access To Safe Blood In Low-Income And Middle-Income Countries: Lessons From India.” BMJ Global Health 2.2 (2017): bmjgh-2016-000167. Web. 21 July 2017.
2. Raykar, Nakul P et al. “The How Project: Understanding Contextual Challenges To Global Surgical Care Provision In Low-Resource Settings.” BMJ Global Health 1.4 (2016): e000075. Web. 21 July 2017.

The author, Ankit Raj, is a final year medical student at Kasturba Medical College, Manipal, and is a member of the International Student Surgical Network (InciSioN).

Note: This article was originally published on BMJ Global Health blogs.

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