2-14 June 2012
First Mission to India
Team members: Andrew Kingsnorth, Hans Lechermann from Germany, and David Earle & Lee Farber from the USA.
Regular readers of Operation Hernia reports will recognise the name Dr Ravidranath Tongaonkar (Ravi), the Indian rural surgeon who over the last 16 years has popularised the use of inexpensive mosquito net mesh for the repair of hernias. Operation Hernia (OH) has adopted this frugal technology which offers poor patients the chance to receive a modern tension-free inguinal hernia repair at no increased cost above that normally charged for a far less effective (and painful) sutured repair. Over the last three years OH has applied this technique in over 3000 patients, and in the process has taught the operation to many local surgeons.
The opportunity to work with Ravi was therefore not to be missed. From the start Ravi worked with speed and efficiency to organise a mission for us, which included 8 days of operating (during which we treated over 134 cases), one day of teaching and a long weekend touring the Eloora and Ajanta caves which are India’s number one and two World Heritage sites (with the Taj Mahal in third position!)
To many of us India is an enigma. A once great empire with the earliest written language, non-confrontational religions, a rich cultural heritage and exotic foods – but now crushed by the weight of a massive population explosion which places 800 million of its people into a position of deprivation and subsistence living. India is ranked as 140th in the world in nominal GDP/capita. It has the largest concentration of people (42%) living below the World Bank’s international poverty line of $1.25/day; half of children are underweight and 46% under 3 suffer malnutrition.
Against this backdrop we worked with Ravi in the 50-bed private hospital that he has built up over the last 40 years, and with his colleague Dr Kulkarni who has had similar but more recent achievements, in Shahada, a town about 20 km away. “Private” is used in the sense that the affordable charges provide them and their families a modest standard of living, while a great number of poor patients, without the means to pay are treated free of charge. The hours are arduous: 6 days a week, 24 hours on-call, clinics with 80-100 patients, end-stage diseases in patients aged before their time. To work in such conditions, cheek-by-jowl with in-your-face poverty requires commitment – and this has been solved by making the hospitals a family affair – husband and wife, and more recently son and daughter-in-law have joined the team to provide paediatric, obstetric and anaesthesia skills.
We were met at Mumbai airport in the heat and humidity of the pre-monsoon season. It was Sunday, so the traffic was less hectic, with less weaving and dodging required by the ubiquitous tut-tuts, which often had impossible numbers of passengers hanging onto fragments of the bodywork, smiling broadly. Perhaps as a foretaste of rural practice we were taken to a plush, private city hospital with high quality facilities and after a typical, delicious spice-laden lunch , headed onto the expressway (recently repaved) to Dhule, the city nearest to the towns of Shahada and Dondaicha. From the coast we climbed onto the magnificently fertile Deccan plateau, occasionally interrupted by jagged, but low-lying mountain ranges. The soil, which is farmed intensively, is only productive if the monsoon rain falls in sufficient quantity each year – and then each family only derives produce from as much land as it rents (or sometimes owns). Irrigation was widespread for fields of rice, wheat, oilseed, jute, fruits, sugarcane and potatoes.
In Shahada we stayed in a low-cost (750 rupees) hotel, that provided a comfortable bed, air-conditioning (AC), an omelette for breakfast, and stupendous curries after the days work, the digestion of which was eased by the local beer (8% proof). At each hospital we received a wonderful traditional “lighting the lamp of knowledge” welcome with garlands, speeches and photo call for the local media. A typical day involved an 8 o’clock pick-up, patient assessment (using the Kingsnorth Clinical Classification for planning the operating list), followed by a 4-table assault on the 16-20 patients operated on each day. Conditions were basic, clean and efficient, with variable AC. Diathermy was intermittent. Nurses, medical students and the occasional surgeon provided assistance, which made up for the poor lighting. Intraoperative Indian music was a dream – even when accompanied by Dave’s singing! Of the 134 patients, 23 were children; many adult hernias were of more than 10 years standing, most patients were painfully thin. Incidental conversations with the patients through interpreters, revealed the average daily wage for a farmer, labourer or artisan (e.g. a tailor) to be about 100-200 rupees (£1 = 75 rupees).
Each evening after the surgery, we were introduced to an aspect of the local community. We visited a village populated by an indigenous community (the constitution of India recognises 212 scheduled tribal groups which together constitute about 7.5% of the population), which felt like stepping back in time a thousand years. We were taken around the local Community College which especially supports the free education of tribal peoples and also housed a Gandhi museum. We hugely enjoyed a Rotarian evening and later had a tour of several of the immense number of projects that the Dondaicha branch supports – including an Eye Hospital with modern-day standards, and a 400 hundred pupil Middle School.
This was an unforgettable trip. Hans, David and Lee worked tirelessly. We travelled long distances together and observed many aspects of India which we enjoyed with humour and good companionship. I think that I will have no trouble in recruiting next year’s team for India