Rural Surgery Presentation at GAPIO Conference: A Summary

THE GAPIO

The Global Association of Physicians of Indian Origin [GAPIO] is an organization that intends to connect the 1.2 million physicians of Indian origin working all over the World. English speaking western world has about 125,000 physicians of Indian origin. The objectives include contributions towards medical education, training and research in addition to networking and social work. GAPIO has been conducting free plastic surgery camps and charitable clinics at Bangalore and Hyderabad. It also has a web portal called Swaasth India portal to network with the members in helping charitable organizations [1].

THE LANCET COMMISSION OF GLOBAL SURGERY

The Lancet commission on Global health was initiated about 2 years ago to address the current inequalities in delivery of global surgery and anesthesia care. The commission has over 100 publications so far from collaborators from 110 countries. The key findings so far are the following:

  • Every year there are more than 5 billion in the world who cannot access safe surgery when needed
  • To meet the surgical needs about 143 million surgical procedures are necessary every year but unfortunately the poorest third of the population receive only 6.3% of the surgical procedures performed all over the world
  • It is estimated that 33 million individuals face catastrophic expenses paying for surgery and anesthesia every year and an additional 48 million have catastrophic non – medical expenses seeking surgical care
  • It is estimated that 28 to 32 % of global burden of disease is from surgical conditions.

Spending more than 40% of the average non–food expenses is considered catastrophic. In most of the low and low–middle income countries any major surgical procedure means 56 percent chance of being impoverished. If the non–medical costs are included in many countries there is more than 94% chance of being impoverished after a caesarian section.

THE KARAD CONSENSUS STATEMENT

The Karad consensus statement was planned to kick start the Lancet commission effort to evaluate and make recommendations for surgical care in rural areas in India. A team from Lancet commission on Global surgery, Association of Rural Surgeons of India [ARSI] and International Federation of Rural Surgeons [IFRS} worked together for months before the meeting at Karad on the consensus statement prepared during the preconference meeting of the ARSI/IFRS conference at Karad in November 2015.

There were three primary groups and the discussions about the following problems that are faced by the rural surgeons.

The Lancet ARSI Consensus

  • Severe shortage of workforce
  • Inadequate rural training programs
  • Accreditation bodies are not coordinated
  • Equipment is not affordable
  • Accreditation standards are irrelevant
  • Uptake of innovation is poor
  • Banked blood is in severe shortage
  • Safe alternatives (UDBT) are not legal

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SHARING RESOURCES AND SUPPLY CHAIN CONCEPT

One of the major problems in rural surgical facility is that the turnover does not support purchase and maintenance of expensive equipment. However if the equipment and human resources could be shared it would go a long way to help the rural surgical facilities. The supply chain concept of finding the most efficient way of meeting the needs of surgical patients in rural areas could provide affordable solution to the needs in rural areas [2].

THE DIAGNOSTIC AND SURGICAL CAMP MODEL

The diagnostic and surgical camp model is an efficient way of meeting the surgical needs of the rural community [3]. Almost 75% of the surgical patients were identified during the diagnostic camps in remote rural areas where all the usual diagnostic facilities available at the hospital were taken and surgeries were offered in nearby rural hospitals. Analysis revealed that it is a cost effective method that makes surgeries available at a very nominal affordable cost to the patients [4]. Donations were required only for the capital needs.

THE SURGICAL SERVICES INITIATIVE

In the past there have been many instances where surgical camps arranged in good faith have caused more problems than good. Hence it was pointed out during the discussions that it is better to have local person coordinating the services of visiting consultants who offer their services for rural surgery. The surgical services initiative has been doing exactly that and has formulated how to go about doing this [5]. More information on the host perspective of the surgical camps and how these could be utilized wisely is found in the experience of visitors to Emmanuel Hospital Association [6]. The initiative offers intelligent and satisfying ways of using the vacations [7].

EQUIPMENT SHARING / RENTING

As mentioned earlier and as indicated by the Lancet consensus statement many of the rural surgeons would love to use modern equipment if they could rent it for a nominal amount that the patients could afford. Philanthropists, Venture Capitalists and any others with money could consider setting up an equipment sharing facility for rural surgeons. It would involve someone to have and look after the equipment and carry them to the surgical facility when needed. It could work out to be a profitable venture too.

ACCREDITATION AND IMPROVING STANDARDS

It is well known that accreditations are of great help in improving the standards. When the standards of the current accreditation bodies are blindly applied none of the rural surgical facilities can have accreditation because many of them use locally trained staff and might not have the necessary infrastructure in place all the time. Hence it is important to have appropriate changes in standards for rural surgical facilities. Organizations like GAPIO should play the important advocacy role in getting these standards recognized. Similarly task specific credentialing rather than qualification specific credentialing would help the rural surgeons. [8]

RESEARCH SPECIFICALLY DIRECTED TOWARDS RURAL SURGERY

The current research in surgery is directed by industry that is interested in profit rather than in serving the poor. Unless specific funding is made available for research directed to serve the poor all the research would be towards making surgery more expensive. There are already several innovations that have and would dramatically reduce the cost of surgery in rural areas. For instance the use of mosquito net for hernia repair instead of the Prolene mesh brings down the cost of mesh hundred fold and large international organizations like Operation Hernia have started using it. Newmon Ventilator is a low cost versatile ventilator. The gasless laparoscopic surgeries would dramatically reduce the cost of minimally invasive surgeries in rural areas.

Examples of rural surgical innovations:

  • Mosquito net hernia mesh
  • Pediatric gastroscope/URS for choledochoscopy
  • Gasless laparoscopy
  • Cytoscope for diagnostic laparoscopy
  • Newmon ventilator
  • Low-cost wound vac

Hence organizations like GAPIO should partner with Academic institutions like Karolinska Institute and Karunya Institute to work on research directed towards rural surgery.

ADVOCACY

The association of rural surgeons of India (ARSI) has been involved in fighting for UDBT (Unbanked direct blood transfusion) to save many lives in rural areas. This is a life saving procedure that the government made illegal for a while that resulted in many deaths and lots of inconvenience. Similarly having radiologists to do ultrasound examinations can also cause inconvenience and deaths. Organizations like GAPIO can help in advocacy to make these lifesaving options available in rural areas.

SUMMARY OF WHAT GAPIO CAN DO

How can GAPIO help?

  • Participate in diagnostic camps
  • Sponsor pilot study in Northeast India sharing human and equipment resources & use of supply chain model
  • Help with advocacy for UDBT, UIS, etc.
  • Sponsor research specific for rural areas

 

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

  1. Available from: http://www.gapio.in/index.php
  2. Available from: http://mdcurrent.in/practice-management/meeting-surgical-needs-rural-areas-supply-chain-concept/
  3. Available from: http://mdcurrent.in/primary-care/diagnostic-surgical-camps-cost-effective-way-address-surgical-needs-poor-marginalized/
  4. J. Gnanaraj, Lau Xe Xiang Jason, Hanah Khiangte . High quality surgical care at low cost: The Diagnostic camp model of Burrows Memorial Christian Hospital. Indian Journal of Surgery Vol. 69, No.6, December 2007 p 243-247.
  5. J. Gnanaraj, Sungtiakum Jamir. Surgical Services Initiative: Taking modern surgery to the poor. CHRISMED Journal of Health and Research 2014: 1 (3) 194 -197 DOI: 10.4103/2348-3334.138900
  6. Gnanaraj J. Working holidays for overseas doctors: Host’ s perspective in mission hospitals in rural India. Christian Journal for Global Health (May 2015), 2(1):35-42
  7. Available from: http://mdcurrent.in/primary-care/enjoy-your-donations-while-those-in-need-benefit-the-surgical-services-initiative/
  8. Available from: http://mdcurrent.in/practice-management/task-specific-credentialing-and-training-for-the-rural-surgical-workforce-a-proposal/


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