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Surgery and surgical training in South Asia
- Ramaswamy Manikandan (3 April 2004)
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Putting the pride back where it belongs
- Aamir M Jafarey (5 April 2004)
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need for current data
- Paul M Fenton (28 April 2004)
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Ramaswamy Manikandan, Specialist Registrar Hope Hospital, Manchester M28 7XT
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Dear Sir, I read this article with interest and particularly the section surgical care and training. The authors have covered this topic in a vivid and explicit manner. I would like to emphasize a few points again. The problem with surgical training in India and I presume rest of the subcontinent is that it is not standardized , as a result what a young surgeon can perform at the end of his/her 3 years training is very variable. With the Consultants and the rest of the staff being underpaid they have no other alternative but to resort to private practice. Some of them have the difficulty in differentiating where government practice ends and where private practice begins as a result they start recruiting patients from the state run hospitals, which is unethical. Again trainees are seen as potential competition and hence there is a reluctance to teach them properly. During their training period some of the young trainees are asked to do odd jobs in order to please the Chief or Consultant, which they do reluctantly as their career, is at stake. The authors state that Hospitals like Christian Medical College (CMC), Vellore should be role models. At CMC Vellore although the staff are paid less they are given free to very subsidized accommodation, children are provided with good education at subsidized rates. If these were to be provided at State run hospitals as well I am sure there will definitely be an improvement in the quality of services. Politics play an important role in the health sector in countries like India. For example in the hospital which is supposedly a pioneering institute where I did my general surgical training we would sometimes run out of local anaesthetics and would have to ask the patients to buy it privately, but this was against government rules and in one instance a doctor was suspended because he gave a prescription to buy some drugs privately as this was not available in the hospital. With people believing politicians telling them that every facility is available and that there is no need for them to purchase anything outside the doctors are at a loss as to what they should do. I still remember trauma patients in our acute wards screaming in pain and with no analgesics to give them. Any health scheme is seen as a potential for making money and unless corruption among the politicians end there is no point looking to the West or for that matter anybody else for help. Why are young doctors heading for the West? Two reasons one for training and the other for money. When I finished my training as a young doctor I felt that I was inadequately trained. Although I had enough resources to set up my own practice I felt I would be doing an injustice to patients if I started treating them at that stage. I therefore came to the UK to get further training. Although it is an uphill task and you have to start from the scratch I thing the best thing here is training is standardized at least at registrar level and above. The other option would be train under an experienced surgeon in my home country itself but then again you would be as minimal wages as possible which might just take care of your house rent and petrol. I therefore think a lot of issues have to be addressed if things were to improve. Restructuring training for example would be a good starter. As stated in the article audit and research are totally non-existent and considered a waste of time and money. I maintained a logbook as I wanted to do my FRCS or else that would be non-existent as well. Competing interests: None declared |
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Aamir M Jafarey, Ethics Fellow Harvard School of Public Health,Building 1-1102B, 665, Huntington Avenue, Boston MA 02115 USA
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Sir, The authors of this editorial have painted a rather pessimistic picture of surgery in South Asia. They point an incriminating finger towards the failure of the public sector in this regard. But surely surgery is not isolated; it shares a similar fate with other disciplines of medicine, be it in education, research or practice. People are still dying of diarrheal diseases, Tuberculosis and Malaria, the last having claimed Pakistan’s premier researcher and chief editor of the Journal of Pakistan Medical Association as its latest victim. This theme emerges at multiple occasions throughout this special issue of BMJ. The public sector has lost out to a much more lucrative private sector in these countries and also to the developed nations. The reasons for this brain drain from the public sector to the private sector or to overseas are multifaceted. An earlier respondent to this editorial has painted a vivid picture for India. Much of what he says holds true for Pakistan as well and I am sure for many other countries of the region. Economic realities are an important factor in the way things have shaped up in South Asia. But it is also clear that the region cannot compete monetarily with the developed nations in retaining its physicians. What then can it offer? Interestingly, the authors have quoted the examples of missionary hospitals or hospitals run with missionary zeal as models of local successes. Is it the zealot physician and medical educator or researcher alone who can make a change for our region? I believe in order to make a change there needs to be a much more broad based approach with a public-private partnership appearing on a local as well as a regional basis. These could be in areas of medical education and research to begin with, one system supporting the needs of the other and both benefiting. These networks would work well not only within cities but also in urban-rural setting if urban based institutions of excellence would be willing to reach into rural communities by lending physicians for periods of time. Many such models can be worked out and which would work well throughout the region. The oft referred outdated British model of medical education needs to be looked at changed to suit the regions needs. This initiative has to be taken up by the teaching institutions and they will have much to learn from each other. Physicians flee to safer havens due to political persecution and, at least in the case of Karachi, for fear of loosing their lives to mindless sectarian violence directed primarily towards doctors. A firm resolve on the part of the governments of the region can contribute greatly in resolving some of the issues. A multi pronged approach with public-private partnerships, governmental support and a spirit of regional cooperation can go a long way in putting pride back into medicine in South Asia. Aamir Jafarey Competing interests: None declared |
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Paul M Fenton, retired France 47800
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I have no doubt that the editorial by Ahmed et al. broadly represents the state of surgery in Pakistan today but the data quoted in reference 1 on surgical output could have been more up-to-date, inferred as 1999. The figures of 124 operations/100,000 population dates from a study conducted in 1983 and published in 1987 (Am J Public Health 1987). The USA output figure of 8253/100,000 pop is even earlier, data collected from 1966-78 and published in Surgery 1981. It is a bizarre fact that we do not actually know how much surgery is carried out developing countries today. Surgeons as a medical genre seem to have little interest in the epidemiology of their own speciality and prefer to discuss individual cases. The authors of this editorial are the rare exceptions. Major aid donors disregard surgery as though it is irrelevant to the health of the population of a developing country. I, as an anaesthetist, published the results of a detailed survey conducted over a 2 year period on surgical rates in Malawi, Africa, in 1997 and came to similar conclusions as Ahmed - there was not enough surgery being carried out. What there was was mainly obstetric.1. However the paper excited little or no surgical comment, nor was any health development aid donor interested in the subject of falling rates of surgical output in Malawi. In fact shortly after that publication the British Department for International Development DFID withdrew funding for the only training school for anaesthetists in the country. Paul Fenton Contributing author to 'Surgical Care at the District Hospital'. Publ. WHO 2003. 1. The Epidemiology of district surgery in Malawi. East & Central African Journal of Surgery June 1997 (3) pp 33-41 Competing interests: None declared |
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