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Making innovative technology work for you

Indian hospitals are frenetically importing every new technology and building glossy mega-hospitals that only 15% of us can afford. But, writes Kavery Nambisan, what we need is innovation that presents simpler and cheaper alternatives. This article by a rural surgeon points to the many innovations already in practice -- from beating heart surgery to the use of mosquito nets for hernia surgeries, and fresh blood transfusions

A “top international story” in The Economist recently praised the philosophy of the east that makes Indian doctors more innovative than their western colleagues. It mentioned the technique of “beating heart” surgery pioneered by Dr Vivek Jawali at Wockhardt Hospital, Bangalore, as an example. This procedure does away with the need for general anaesthesia or blood-thinners to prevent the clotting of blood in circulation. It is so safe and successful that medical tourists have begun to flock to the hospital.

The article also mentioned the advantages of innovation in the making of medical equipment. It quoted two examples from high-profile hospitals as typical of Indian doctors constantly striving to be “affordable” to ordinary people. Shivender Singh, head of Fortis Hospital in Delhi, has realised in the last few years that the frequent purchase of new, expensive diagnostic machines when the old ones are functional is unnecessary. “We opted out of the arms race a few years ago,” he says.

Dr Pratap Reddy, the ‘Father of Apollo Hospitals’, is suddenly tired of treating the affluent in cities. He wants to open small and medium-sized hospitals in smaller towns, benefiting these people like their city brethren.

God forbid. I don’t mean to throw icy water on Dr Reddy’s noble aspirations but I hope Dr Reddy will have a rethink. Until high-tech users like the Apollo Group choose to put need before greed and genuinely understand the dynamics and requirements of small towns and villages, such forays into the periphery are bad news.

The article in The Economist talks about innovative technology in the field of laparoscopy, diabetic monitors and cardiac equipment. As always, the western media relates best to issues surrounding diseases they are familiar with. They are especially alert when their own people, in the form of medical tourists in India, have benefited.

Dr Jawali’s beating heart technique is the only novel procedure cited in this half-page article. A very small percentage of Indian doctors are cost-conscious, with a view to helping the patient. Several others pretend: private hospitals which have made medicine a business have a charitable wing providing “free treatment” to 10% of patients. This is largely a publicity stunt, useful in the purchase of subsidised government land or to get exemption from import duty on sophisticated medical equipment.

We Indians are a strange people: We pride ourselves on our eastern heritage but follow the western precepts of progress. In medicine, we import technology, build mega-hospitals and have succeeded in catering to the rich. Cardiac centres and kidney hospitals, fertility centres, laparoscopy and lithotripsy clinics with a hospital administrator, marketing manager, public relations officer and an advertising panel are the trend even in our smaller towns. Who but the patient pays for the excess? Such hospitals invariably spend a fortune on equipment, electricity, salaries and gloss. A mere 15% of our population benefits from such frenetic advances, while millions die for want of money to avail of any of this expensive treatment.

There are exceptions of course. Recently I was in need of an angiogram as investigation for unexplained breathlessness. Since I live in Lonavala, which is without such amenities, I went to Nair Hospital in Mumbai. This congested government hospital has a fine cardiology department headed by Dr Chaurasia. It caters mostly to the poor and the average middle class. I had the angiogram done there and although it did mean a total absence of any luxury, the procedure went well. The cost was 20% of what I would have paid privately. As a doctor I might have got a certain amount of extra attention, but I did not fail to observe the efficiency, the respect for stringent asepsis and obedience to medical protocol in dealing with every patient. There are others like Dr Chaurasia and his team but they are overshadowed by those who find themselves guiltlessly denying their much-needed services to ordinary people.

Affordability and easy access are the two essentials of healthcare. Ironically it has taken a major, global economic recession to bring home the point that health systems everywhere in the world must cut costs. Being conservative about the purchase of new equipment would fit into this objective. But by itself it cannot reform healthcare until the concept embraces every dimension of medical care. Innovation must take us outside the bubble in order to look for alternatives that are simpler and less expensive. Dr Jawali’s technique of beating heart surgery, which simplifies all aspects of patient care before, during, and after surgery, is indeed an excellent example.

A simple and affordable device, which I recently read about in the Journal of Rural Surgery, is the use of discarded Uro bags (lined with stiff cardboard and reinforced with used plastic tubing) as an abdominal support after surgery. It costs nothing and is a boon to patients who need it temporarily.

Innovation does not begin with technology which, by the way, is not a monster we must kill off or maim. Progress is essential in every sphere of life. Even the humble rice vessel or the frying pan has evolved to suit our needs. True progress meets needs that are real. How far removed our modern society is from wisdom is obvious from the recent economic crisis. Every politician, businessman, banker and corporate honcho is waiting for “an upswing in consumerism”. They want the innocent householder to go out on a spending spree. Have we reached that point of no return where we must keep spending in order to survive as a civilisation?

It is not yet time to lose hope.

Our government conceived of a socialised system of medicine that would reach everyone; it hasn’t made it work. So, for now at least, we have to contend with a combination of government and private systems that are beneficial and affordable to every patient and also favourable to the doctors who practise it. This challenge of making two goods co-exist is something that seems to elude us. But there are doctors, working mainly in the periphery and away from any hype or attention, who have grasped the secret. They are creative and constantly evolving ways in which to cut needless spending.

In the early-1990s, Dr Brahma Reddy, working in a rural hospital in Andhra Pradesh, claimed that mosquito net material when properly sterilised can be used for mesh repair of hernias. The usual practice in India, as everywhere else, is to use imported prolene mesh which costs several thousand rupees for a single case. The mosquito net material, which is a co-polymer of prolene and polyethylene, is autoclavable and as good as the prolene mesh. Between 1996 and 1999, 359 hernias were operated on in four different centres in India using mosquito net. The infection rate was 4.7%, but there were no cases of mesh rejection.

Many surgeons like myself have been using the mosquito mesh with excellent results. It is available in sterilised packs and costs the patient no more than Rs 20 or 30. Its use has been written about in surgical journals in different parts of the world, but our own city counterparts are still hesitant to use it. There is always the suspicion that something so simple might not be very good. A difference of a few thousand rupees to the patient isn’t significant in the context of their practice.

In the 1980s, when rural hospitals could not dream of cardiac monitoring, I worked with an anaesthetist who devised his own monitor, using a long-tubed stethoscope with a single earpiece. The diaphragm was taped to the patient’s chest so he could move about the room during surgery and still monitor the heartbeat. He saved several lives using this technique.

Once when I was operating on a six-year-old with a ruptured bladder, the patient’s heart stopped and his temperature soared to 107ºF. It was the first case of malignant hyperthermia that we had seen, and there was no one to consult. So we did the best we could: chunks of ice were fetched from the refrigerator and the boy’s abdomen washed repeatedly with litres of iced saline. He survived. I must add that this anaesthetist had no formal postgraduate degree in that field. A few years later, I saw a similar case in the UK when watching a plastic surgery procedure for ear deformity in a young nurse. She developed malignant hyperthermia, was rushed to the ICU and put on a ventilator. Several specialists supervised her treatment but she did not survive.

An important example of innovation that saves countless lives in rural areas is fresh blood transfusion. Official blood banks need expensive equipment, air-conditioned rooms, specially designed refrigerators and specially trained personnel. A basic set-up costs upward of Rs 10 lakh just to get started, and a continuous source of electricity. This is impossible in most rural hospitals. Doctors therefore use fresh blood from the donor to the patient. This is called Unstored Direct Fresh Blood Transfusion (UDBT). The donor’s blood is checked for compatibility and safety, using WHO guidelines, before transfusion. It is safe, effective and saves much expense and trouble for the patient’s relatives who would pay a lot more to get stored blood from an ‘official’ blood bank hundreds of kilometres away. With fresh blood, if the testing is done with care, chances of complications are negligible.

It is imperative that the authorities ensure that UDBT is carried out with scrupulous attention to safety. But to simply categorise it as illegal will deny life to thousands of patients. What is strange is that using UDBT under emergency conditions in the army is considered safe and legal if it is done “to save a precious life”. Is the life of a soldier more precious than that of a villager?

Rural surgery is a vital sector in the healthcare of the nation. The Association of Rural Surgeons of India (ARSI) was started in 1992 by a small group of committed surgeons. The first conference of the Association was held in Sevagram, Wardha, where Mahatma Gandhi -- that genius of commonsense -- started the movement to make villages self-sufficient. Three years ago, a decision was taken to start a three-year course in rural surgery affiliated to the National Open University, in order to offer the benefit of all-round training, so essential in villages.

At the annual conference where surgeons present cases and exhibit innovative procedures and gadgets, there is much to learn. Every year, I come away carrying with me the benefits of another surgeon’s experience. A doctor in Bihar performs a wide variety of surgery (gall bladders, appendectomies, hysterectomies, hernias, haemorrhoids, Caesareans) under local anaesthesia. Another does thyroidectomies in violence-ridden Jammu and Kashmir under local. A doctor couple in interior Tamil Nadu teach the technique of nursing and safe delivery to tribal girls…

Innovation is essential in all frontiers of medical treatment. A hospital that decides to look clearly at wasteful expenditure caused by too much lighting, needless use of heating and cooling systems like air-conditioners and geysers, wastage of water, and improper disposal of waste is far more progressive than another which does not consider it important.

The fascination with frenzied progress and escalating medical expenses has resulted in negligible benefits to common people. To change this mindset and think of cheaper alternatives is as essential in affluent nations as it is in India, Africa or China. Hopefully, the present need to economise will bring about this much-required revolution in medical care.

(Kavery Nambisan is a surgeon who has spent most of her career working in rural areas. She is also the author of several books. Her novel The Hills of Angheri (Penguin India) deals with the conflicts and concept of success and failure in a doctor’s life)

Infochange News & Features, December 2010