The last patient we saw at a clinic in India encapsulated virtually the entire experience shared by a group of Fellows of the American College of Surgeons (ACS) who traveled to the developing nation in 2011. The team had just completed a day of staffing a free clinic in the rural Haryana province when the parents arrived with their infant daughter. They had to travel by foot, so they were understandably late, disheveled, and anxious. It was their hope that the American physician could cure what ailed their seven-month-old baby. At first glance she appeared typical, with kohl eye shadow and red lips from betel seed. However, when the infant cried, her nail beds turned distinctly blue. An exam with a stethoscope revealed the loud systolic murmur.
The team had traveled to India as delegates of People to People (P2P), an organization started under the direction of President Dwight D. Eisenhower, which promotes cultural exchange tourism. P2P sends hundreds of Americans on cultural exchange programs around the world every year. Originally a not-for-profit organization, P2P is now a for-profit company with 50 years of experience in the niche industry of tourism that combines the usual sightseeing with a more in-depth volunteer experience. P2P has sent thousands of high school students on exchange programs; more recently they have found success at arranging programs for professional adult travelers.
This delegation was known as the Surgical Leadership and Service Delegation—the first group that P2P had organized with members of the ACS. P2P had sent many other delegations to India in the past, including teachers, engineers, nurses, and other physician groups. The ACS delegation would learn about the health care system in India, meet some of our surgical counterparts in the region, and visit some of India’s sites. Participation in the free clinic was our last professional activity of the trip.
Building a delegation
P2P first contacted Mark Savarise, MD, FACS, a coauthor of this article, in the spring of 2011 during his tenure as Chair of the College’s Young Fellows Association, proposing that he serve as delegation leader. The process started with the development of some objectives for the trip, which were as follows:
- Develop an understanding of the impact of India’s culture on its current medical care system
- Learn about the economic forces that affect surgeons in India
- Gain exposure to the surgical conditions that are unique to India
- Attain an understanding of medical tourism from the perspective of the Indian surgeon
P2P sent invitations to potential surgeon participants throughout that summer. “I decided to go because I thought it would be an opportunity to learn about the health care systems that are available in developing countries,” said pediatric surgeon Joelle Pierre, MD, an Associate Fellow of the College in Valley Stream, NY. “I had never considered going to India before but felt that this was a unique opportunity, and the information could be translated to [the needs of] other countries.” Typically, P2P delegations include between 15 and 30 participants. By August, our delegation included only eight members; however, P2P decided to proceed with the delegation as this was their first group of ACS members.
Adrienne Fueg, MD, FACS, a general surgeon from Saint Mary’s, PA, said she decided to participate in the mission because “It was right after the revolt in Egypt. I thought it would be interesting and safe to travel to a place I wouldn’t go to on my own. The ACS name was associated with it so I felt it was legitimate,” continued Dr. Fueg. “When I received the to-do list from P2P, I started having second thoughts.” The process for obtaining the visa, including surrendering her passport, as well as the vaccinations required for this type of mission were a challenging undertaking, according to Dr. Fueg. “I never gave any thought to all the diseases I would be exposed to. [But] I have no regrets. The experience was so eye-opening. It’s the first time I’ve seen how the other half—well, three-quarters—live.”
The journey begins
The 14-hour flight from the Newark Liberty International Airport, New Jersey, deposited the delegation at the Indira Gandhi International Airport in Delhi at 10:00 pm on a Sunday night. Sandeep Singh, an imposingly tall man in a crimson turban, met us at the airport and would be our guide for the week. Mr. Singh did more than take us to our various destinations. He kept us on schedule, guided us through the throngs of people, acted as interpreter, bargained with hawkers and vendors, steered us to the best dishes on menus, and made sure none of us got lost during the week. He did all of these tasks with patience and skill obtained through years of leading groups of Americans. His first responsibility was to shepherd the group and its luggage into our tour van and into the chaos of a Delhi traffic jam in the middle of the night.
The delegation’s itinerary was arranged by P2P, more precisely by the company’s contacts in New Delhi who were skilled at negotiating meetings with peers in and around the city.
The first morning started with a briefing during which several delegates learned that their experience would include hands-on care of patients, something even the delegation leader found out only days prior to departure. Balu Menon is responsible for arranging the professional interactions of P2P delegates in India. He had arranged for previous medical groups to tour the Deepalaya clinic and school in the Sohna village, but Mr. Menon had arranged a more ambitious plan for the surgeons on this trip. Because our mission was titled Surgical Leadership and Service, this group would spend one day of its cultural exchange in service to the community. “My major concern at this point was the fact we would be delivering primary care, something I had truly never had to do since medical school,” said John J. Como, MD, MPH, FACS, a co-author of this article.
Economic and cultural realities
The itinerary would also include tours of three hospitals in Delhi and an exchange with the physician staff at each facility. Our Indian counterparts had been given our list of objectives prior to our visit. Notably, interspersed with daily professional activities were visits to historic sites in the area.
The first hospital the delegation visited was the Fortis Flight Lt. Rajan Dhall Hospital. Nearly the entire surgery department participated in the meeting held that afternoon. The surgeons were very interested in speaking with the ACS delegation about the Indian medical system. Many of the physicians had completed some of their training in the U.S. or Europe and could readily explain the differences between the health care systems.
India has a two-tiered health care system; the Fortis hospitals are part of the private sector, providing care to the 14 percent of Indians who carry health insurance or pay for their care. They also provide 10 percent of their care free of charge.
Most Indians rely on the public health system, which is fully funded by the government. In the private system, costs are about one-tenth of those in the U.S. During the tour of the hospital, it was apparent that the medical facilities were similar to those at most American hospitals, so the cost savings were not completely at the expense of the level of care. The staff pointed out the factors that contribute to the large cost disparity:
- Physicians earn less than their counterparts in the U.S.
- Drugs and devices cost much less in India than in the U.S.
- There is less pressure to perform potentially unnecessary services in India.
- Indians routinely use cost-saving measures, such as the reuse of items.
- There is much less liability pressure in the Indian health care system.
- A private room costs $68 per day, although most patients were on wards for a fraction of that cost.
The Indian physicians are aware of the effects that westernization will have on the system as their economy expands, including an increase in the cost of care and use to a point where workforce shortages will be severe.
A member of our delegation, Jagdish S. Gill, MD, FACS, a general surgeon in Sioux Falls, SD, has family ties to India; in fact, his mother still lives there. Dr. Gill coordinated his trip to include a visit with her and was surprised at how much he learned about India during the trip. “I was unfamiliar with People to People and first saw their notice in the Bulletin of the American College of Surgeons. I was intrigued to see the medical treatment applied to patients in the third world,” Dr. Gill said. “I learned a great deal about the business of medicine and the delivery system in India.”
The ACS delegation noted that the private hospitals seemed to lack facilities for obstetric or pediatric care and that the emergency departments were not much more than simple receiving areas for trauma patients. India, in fact, provides very little pediatric specialty care and very few obstetric services. Most deliveries are done at home, and infant mortality is significantly greater there than in the West. Economic and cultural realities simply do not permit large expenditures of resources for children from the areas with the greatest demonstrated needs.
The lack of trauma systems revealed another reality of India: its infrastructure cannot facilitate rapid response and transport of injured patients. In other words, there is no Golden Hour for Indian trauma patients.
Public health issues
The next day, the delegates’ orientation continued at the Maulana Azad Medical College, which is affiliated with the University of Delhi and is one of the public teaching hospitals in the city. The physicians had prepared presentations for the ACS delegation on the communicable and noncommunicable diseases common to India, and on the Indian public health sector. Because of the country’s longstanding economic disparities, India still endures many endemic infectious diseases. However, as India’s middle class develops, the nation now is facing epidemics of the noninfectious diseases of the Western world, including arterial disease, cancer, and skyrocketing rates of diabetes.
Two surgeons—Distinguished Professor R.C.M. Kaza, MB, BS, and Anil Agarwal, MB, BS, FACS—were especially helpful in explaining the situation for surgeons in India. In training, Indian surgeons have experience in laparoscopy, robotics, endovascular techniques, and complex oncology surgery; however, in practice, they have limited opportunities to perform these procedures outside of major training centers in large cities, adding to the shortage of surgeons in smaller cities and rural areas with limited resources.
In fact, the discrepancy in the surgical and other specialty care provided at large, urban, public hospitals and the services provided at rural public facilities is significant, clearly demonstrating how India’s caste system affects health care. Corollaries to this problem are high rates of infant mortality and even occasional instances of “honor killing” of young women.
The delegation’s final day of learning about modern Indian health care was also the most impressive. Medanta Medicity—a two-year old hospital that is in the process of expanding from 600 to 1,200 beds—is located in two spotless towers in the Delhi suburb of Gurgaon, the technology capital of India. The chief of surgery, Adarsh Choudhary, MB, BS, explained that he performs more than 100 Whipple procedures annually with a very low morbidity rate.
Sandeep Malhotra, MB, BS, FACS, another surgeon at this facility, received training and was an attending surgeon in the U.S. He returned to India for the sake of family. Dr. Malhotra was very open in offering his insights into the practice of general surgery in modern India. He was able to highlight the contrasts between his life and ours. Although he earns less, Dr. Malhotra is able to employ a chauffeur and servants. He has a great deal of control over his practice in the private sector. However, he noted that the quality of nursing care is not as good as it is in the west and that Indian physicians receive less training in critical care.
In the trenches
The delegation traveled less than 20 miles from the Medanta Medicity to the Deepalaya clinic, the final locale during the cultural exchange visit, which is located near the rural village of Sohna—but it may as well have been 1,000 miles for the difference in the patients we met the next day. The Deepalaya school and hostel are funded and administered by the Deepalaya Foundation, an international resource group, which has also built a health clinic at this location. Our delegation was greeted by the school children who performed traditional songs for us in Hindi and Urdu. The team toured the hostel and met with a counselor, who discussed the difficult upbringing of some of the children in the facility, as well as some of the success stories of their graduates. The donation process was explained to the delegation, including how a British company donated 50 computers to the school. We also got a sense of the hardships of life in Sohna and what the school has done to accommodate the residents’ need to increase attendance at the school. For example, the school year is adjusted so that students can work on the farms in the planting and harvest season. Also, with multiple religions, the school has had to be very sensitive in this regard, but the facility successfully places Hindu, Islamic, and other students together into classes and dormitories.
The delegation was then transported to the village to meet the locals. Custom dictated that we were separated into male and female contingents. The men encountered a group of about 30 local males, at which time the delegates received their first glimpse of the medical problems in the community. An elderly gentleman, obviously of some local importance, had a dirty gauze bandage on a chronic wound on his leg. The stigmata of his peripheral vascular disease due to diabetes and chronic smoking were obvious and more easily appreciated by the locals than the explanation for the wound’s poor healing.
The women joined a support group in one of the homes, where the village women described their programs and their business success. It was hard not to note the contrast of the dusty surroundings with the brightly colored saris and scarves of the crowd.
The next morning, there was a great deal of anticipation for the day of medical service to the Sohna village. None in our delegation of three general surgeons, a trauma surgeon, a hand surgeon, and a pediatric surgeon had much experience with medical missions, and it had been years since any of us had done any primary care. However, the large number of patients seeking help were uninterested in our specialty credentials but very eager to seek our help. Even our one guest traveler, the physical therapist wife of one of the surgeons, was going to participate.
When the delegation arrived at the hospital, a small number of patients had already gathered for registration. This number quickly grew as news of our presence permeated the community by loudspeaker and word of mouth. The clinic started at 9:30 am and continued until 2:00 pm. The time flew by quickly as we began to see the patients who were led to the facility one by one with the aid of an interpreter.
The delegates had learned previously that Indian patients are generally wary of Indian physicians, whom they perceive as primarily interested in making a profit by ordering tests, performing procedures, or ordering treatments. These patients, we were told, would be much more trusting of the motives of the ACS group of volunteer American physicians.
The patients presented with a host of ailments, including abdominal pain, back pain, kidney stones, neurologic deficits, cataracts, carpal tunnel syndrome, skin diseases, peripheral vascular disease, and diabetes. Some brought their records from local clinics (which seemed to be generally very accurate). We obtained histories with the help of our translators, performed physical exams, made diagnoses, prescribed from the limited pharmacy, and performed minor procedures.
The delegation had planned to break into teams of two for patient visits. In light of the patient volume, we soon decided to double our efforts. We pressed into service our P2P guides and administrators as interpreters. Our physical therapist was directed to evaluate and treat musculoskeletal problems, while a social worker—who had arrived at the school from Britain days before—worked to coordinate patient flow. The pharmacist and nurse who regularly staffed the clinic were kept constantly busy.
“Very quickly all of the general medicine and pediatrics I had purposefully pushed to the recesses of my mind resurfaced,” recalled Dr. Pierre. “Seeing that many patients in such a short amount of time without being encumbered by an EMR [electronic medical record] was exhilarating. At times, I felt overwhelmed by the inability to help those who were in need of additional specialized care, especially since talented specialists seemed just out of their reach.”
By 2:00 pm, the ACS delegates had provided care to more than 150 patients. It was amazing to see, despite language and cultural barriers, the appreciation of the patients as we each took time to listen and treat their individual problems. They showed a level of gratitude that we do not always experience in our day-to-day practices in the U.S. At the end of the clinic, the delegates were treated to lunch at the school, a cultural performance by the students, and a game of cricket.
It was at this point during the exchange that the delegation met the parents of the infant girl with Tetralogy of Fallot mentioned at the beginning of this article. The diagnosis had already been made at a small town clinic where a very good ultrasound had been performed, but the parents were hopeful that the American physicians would be able to do something to help her that, perhaps, the Indian physicians were unwilling or unable to provide. Having completed our introduction to health care in India, we knew at some level that the girl was not going to survive. Her only hope would be to make it to one of the very few cardiac surgeons in the city who could repair the defect. For her parents, pursuing this option was going to be an impossibility. For us, it brought home the realities of India—that the massive population, pervasive poverty, limited supply of surgical specialists, and deeply entrenched caste system continue in the 21st century and prevent some patients from getting care that would be provided in our country.
“I remember feeling how little we were able to do to actually help—for example, with the patient who needed an aortofemoral bypass,” recalled Dr. Como. “Some basic primary care, with access to specialists as needed, would have been invaluable for these patients. Instead, many will never get the help they need, and in fact, may die of their ailments. There is only so much anyone can do in one day,” said Dr. Como. Dr. Gill added, “There was a much greater need than we could accommodate. Since returning home, I have attempted to contact Indian physicians in the U.S. to organize some international efforts that go beyond where we have gone.” Specifically, Dr. Gill has contacted the American Association of Physicians from India and is working to organize volunteer rotations.
After four days, the College delegates had seen the spectrum of health care in India, from the private rooms and high-tech wizardry of Medanta and Fortis, to the strained but dedicated public hospital and medical school, to the underserved villages and the grateful, hopeless poor in Sohna. Interspersed with these activities were visits to tourist attractions, including temples, mosques, and markets and a stop at Mahatma Gandhi’s modest memorial—not to mention the view of daily life of some of the 20 million residents of Delhi and the other millions in the countryside through the windows of our bus. At this point, only a visit to Agra and the grandeur of the Taj Mahal remained on our agenda. To call it a whirlwind exposure to this culture halfway around the globe would be an understatement.
Our group had a bit of informal debriefing at our farewell dinner and in the departure lounge at the airport. We all agreed that we could not call the week a vacation in any sense of the word. For some, it had been the most intense week since residency training, but all concurred that the experience had been worth it. Each of us would take home a slightly different meaning from the experience, including an understanding of India in a way that is not easily conveyed through words or even photographs—the juxtaposition and harmony of a blossoming economy and absolute poverty, of dirt and color, of despair and happiness that is everywhere.