On Location-India, May 2007
A vibrant country, India is the seventh largest and second most populated in the world. With a population exceeding one billion, steeped in a pictorial history dating back 7,000 years, India remains the world’s largest democracy. It is multi-ethnic multi-religious country with a predominant Hindi religion/philosophy, and a secular government. Along with neighboring China ( figure 1, Map of India; figure 2, Tea plantation; figure 3, Young Indian school children; figure 4, “Indian family car”), India has advanced from a former British colony to a developing independent country. India is now an emerging economic world power with all the attendant problems and challenges, especially poverty that is spawned by educational and health care issues, and a lingering caste system.
Recent educational spending is 4.1% of GDP and health care spending is 4.8% of GDP (1). The Human Development Index (HDI ) of India is 60 (1). The HDI measures 3 indices: GDP, adult literacy combined with average years of schooling, and life expectancy (for India- 64 years). HDI > 80 is high, 50-79 medium, and < 50 low. Comparative data is summarized in figure 5, India economic statistics (2).
The health care system / structure of India is predominantly socialized at the central, state, and district levels, but is changing rapidly with the emergence of free market privatization of health care services. As of 1992, there were 22,400 primary care centers, 7,300 acute care hospitals (4,000 governmental, 2,000 charitable trust, and 1,300 private) (3). There were more than 320,000 doctors or 3/10,000 population, 220,000 nurses, and over 130 medical schools or colleges, including both public and private.
As with most emerging economies, there is a double burden of disease in India, i.e. chronic non-communicable disease, and the lingering burden of communicable disease, especially tuberculosis, HIV/AIDS, and malaria ( figure 6, India mortality/ disease adjusted life years (DALYS) (4)). To be noted is the high mortality of cardiovascular disease, which is becoming epidemic, especially in the urban areas. DALYS represent the years lost from premature death combined with years lost from disability.
Traditional medicine is the oldest Indian science. It is rooted in yoga practices that stress a holistic approach to health that is based on proper diet and exercise (5). Dating back to the 6th century B.C., this ancient system of Indian medicine is known as Ayurveda, or the science of longevity and life. It is still widely practiced, and gaining in world-wide popularity.
India ’s oldest medical text is attributed to Caraka in the second century B.C. (5). Surgery appeared in the medical text developed by Sushruta in the 1st century A.D. (6). This collective surgical treatise, Sushruta Samhita, became the foremost branch of the healing art and the first of the eight branches of Ayurveda (6). Surgery included eight categories: incision, excision, scarification, aspiration, extraction, secreting or evacuating measures, probing, and suturing ( figure 7, Ancient Indian surgical instruments) (6).
With the colonization and domination of India by Great Britain from 1600 to 1947, exposure to Western medical style and practice, and English as a major spoken and written language after Hindi / regional dialects, Indian medicine and surgery advanced slowly but progressively. Over the past 25 years medical care has accelerated. The Medical Council of India, established in 1933, continues to establish, maintain, and advance the standards of medical care and graduate medical education/training. Following 5.5 years of medical school, training in cardiothoracic surgery is six years (3 years general surgery and 3 years CT surgery). This culminates in the MCh degree (government hospital) or the Diplomate of the National Board of Surgery—DNB (private or charitable trust).
Presently there are more than 50 training programs with about 60 residents completing training per year. Over 1,000 CT surgeons perform cardiothoracic surgery in over 175 centers. The annual caseload for cardiac surgery is between 70 and 80 thousand, of which > 60% are coronary artery operations. The annual caseload has doubled since 1995. This increase is directly proportional to the emergence of the increased out-of-pocket paying population (7, 8).
The notable advance in centers, caseloads, number of trained CT surgeons, increasing basic/clinical research, and indigenous design / manufacture of medical equipment/supplies is offset and challenged by the awareness and concerns of cost, access, waiting lists, quality of training, academic progress, and human subject clinical research. A better understanding and appreciation of these issues was gained during a 3-month stay in India from January-April 2007 as a guest visiting cardiothoracic surgeon of Dr KM Cherian ( figure 8) at the Frontier Lifeline Cardiovascular Centre in Chennai. The activities included participating in the First International Rural Cardiac Care Conference in Parumala, Kerala, India February 10-11, 2007. This conference boldly addressed the major challenges facing cardiac care and surgery in India. Since 65- 80% of Indians live in rural areas, this segment of the population is least served by the health care system. Observing and first assisting on cases both in Chennai and the Frontier Lifeline sponsored rural St Gregorios Cardiovascular Center in Parumala afforded a unique opportunity to gain insight into the everyday concerns, joys, and frustrations of patients, families, and the health care team.
These concerns, observations, and recommendations can be summarized:
1. Cardiac surgery growth favors India, given that 10-20% are middle income by western standards, and have access to a number of outstanding state of the art centers e.g. ESCORTS, Apollo, Fortis, Frontier Lifeline).
2. Unfortunately, valve and congenital heart disease lags behind coronary disease. The waiting lists for the former continue to rise, especially in the government hospitals. Fewer than 10 centers perform complex congenital procedures, yet the results are excellent in those centers. An estimated 6 million Indians are in need of cardiac surgery (42 operations / million in India vs. 1,700/million in USA ), of which over 1.5 million are congenital (8, 9).
3. Existing centers from all sectors have not developed a consensus for strategies to address the alleviation of this burden of disease.
4. The training programs, though organized and structured, suffer from imbalance, with only a few centers producing well rounded experienced responsible trainees ready to operate / practice on completion of their training, e.g. All India Institute of Medical Sciences.
5. Research has advanced remarkably especially in stem cell / tissue engineering, minimally invasive surgery, and advanced devices, including robotics.
6. India stands in the enviable position of learning from the shortcomings of the western programs, especially in the area of the relationships with government and corporations. The vision of CT surgeons, like Dr’s KM Cherian and N. Trehan in establishing futuristic medical cities will be closely watched.
7. The role of foreign help or participation in Indian CT surgery, evolving from individuals or teams coming to India for short term training and performance of operations, will decrease as the quantity and quality of cardiac surgery continues to grow. Specialized operations and projects will be the mainstay of foreign participation and cooperation. The era of Dr Reeve H. Betts from Boston (the father of Indian CT surgery) coming to India as a medical missionary in the 1940’s has passed. Fewer Indian CT surgeons are seeking accredited or non-accredited training abroad. A number of Indian CT surgeons have gained immensely from their non-accredited fellowships abroad, e.g. Dr Albert Starr’s fellowship program in Portland, Oregon.
Dr AS Kumar (10) has nicely summarized the 2 major needs for cardiac surgery in India : 1. though there is an adequate number of qualified Indian CT surgeons- -“productivity is limited for want of well-equipped hospitals.” 2. cost of care: a coordinated effort must be made to make quality care available at affordable prices---“at All India Institute of Medical Sciences we provide Texas Heart Institute quality at Yusuf Sarai prices.”
Collaboration and cooperation with our Indian colleagues must be based on a desire and willingness to listen to their wants and needs. They have more insight into their own country. We can learn from them. The excitement, enthusiasm, and desire to extend cardiothoracic surgical services are a joy to observe. Needless to say, the explosive growth of CT surgery will parallel the social / political / economic growth.
Thomas Pezzella, MD
Director of Special Projects
World Heart Foundation
References
- The Economist-Pocket World in Figures- 2007 edition. Profile Books Ltd. London, 2006: page 30, pages 156-157
- Flavin C, Gardner G. Ch 1 -China, India and the New World Order. In: The Worldwatch Institute—State of the World 2006. WW Norton, New York. 2006; page 3-23
- Health Care- India. http:// www.indianchild.com/health_care_in_india.htm (accessed 4/2/07)
- Reddy, KS, Shah, B, Varghese, C, Ramadoss, A. Chronic Diseases-3- Responding to the Threat of Chronic Diseases in India. Lancet 2005; 366:1744-1749
- Wolpert, S. India. U. of California Press, Berkeley,CA, 1991; pages 192-193
- Mukerjee, S, Gupta, T. Surgery in India. Archives of Surg. 1997; 132:571-578
- Murthy, BS. Presidential Address- Glimpses of My Thoughts. 50th Annual meeting of Indian Association of Cardiovascular and Thoracic Surgeons. New Delhi, February 19-22, 2004
- Cherian, KM. Management of Complex congenital heart disease: Indian Experience. Indian J. Thorac Cardiovasc. Surg. 2004; 20:S64- S70.
- Padmavati, S. Development of cardiothoracic surgery in India. Indian J. Thorac Cardiovasc Surg . 2004; 20 S50-S52.
- Kumar, AS. Editorial: Half Gone, half done. Indian J. Thorac Cardiovasc. Surg. 2004; 20: S1- S2.
