Dr. Ravindranath R. Tongaonkar,
(Past-president ARSI and Joint secretary IFRS)
Dondaicha, Dist. Dhule, Maharashtra, 425408, India
Date: - 30th May 2010
Association of Rural surgeons of India (ARSI) has played a vital role in bringing the rural surgeons of the World together and in the formation of International Federation of Rural Surgery (IFRS). It may be worth to know the evolution of the concept of rural surgery especially in India and what we rural surgeons expect from an International body like IFRS.
Rural Surgery was in vogue from time immemorial when Shushrut, the first documented Indian surgeon first did his surgery in India. Famous Mayo clinic was started in a village and across the world many surgeons were rendering their services to rural population. But rural surgeons were never organised as a community or as an ‘Association’ as against their other colleagues like physicians, surgeons, gynaecologist, urologists and now hundreds of super and minor specialists who come together and form their ‘Association’ or ‘Federation’.
The rural surgeons showed their presence sporadically, presenting their work in conferences. (I presented papers on ‘rural surgery’ first time in 1976.) Occasionally teachers like Prof. Udwadia organised a symposium on ‘Training of a rural surgeon’, as he did in 1983 at Kathmandu (Nepal) inviting a rural surgeon like me to participate.
But the first attempt to bring the birds of the same feathers together was initiated in India in 1987 by the then President of Association of Surgeons of India (ASI), Prof. Rangbhashyam & President-elect Dr. Udwadia, who informed us about the formation of ‘Rural health care committee’ by Association of Surgeons of India (ASI) under the chairmanship of Dr. R. D. Prabhu, Immediate past-president of IFRS.
The Rural Health Care committee (RHCC) suggested many things to ASI; it conducted a nationwide survey of rural surgeons and found out the working conditions of the rural surgeons in India. Some of the findings related to availability of qualified nurses, and other paramedical staff, how many surgeons have X-ray machines, have their own Laboratory and other technical facilities. How many can avail of qualified anaesthetist and how many give anaesthesia to their own patients and so on.
The Rural Health Care Committee also started special rural surgery ‘Sessions’ during the annual conferences of ASI.
Even though the subsequent ASI Presidents Dr. Udwadia & Dr. Mrs. Deshmukh encouraged rural surgeons, the organisers of the ASI Conferences did not pay any heed to rural surgery sessions, many times not giving us a hall or even a projector for our sessions. We had to do the sessions in veranda.
ASI office did not give any funds to our committee chairman, even for correspondence with other committee members, or remuneration to our invited speakers.
Therefore we demanded a ‘Rural Surgery Section’ of ASI so that we could raise our own funds from section membership but we were denied the section saying that ‘Rural Surgery’ is not a speciality. (The section was sanctioned 5 years later with formation another parallel organisation of– Association of Surgeons of Rural India- A.S.R.I.).
Thereafter we decided having our own association of rural surgeons.
Fortunately enough we got the able guidance of stalwarts & national figures like Dr. Balusankaran the Ex-Director General Health Services of India & Dr. N. H. Antia, Director of Foundation for Research in Community Health.
Under their leadership the Association of Rural Surgeons of India was founded in Shimoga, Karnataka, on 29th Nov 1992 by eight persons who were keen on promoting philosophy of rural surgery. Besides the above two, there were Dr. Venkat Rao, Dr. R. D. Prabhu, and Dr. J. K. Banerjee, Dr. R. R. Tongaonkar, Dr. R. P. Pai and Dr. Mrs. Asha Tongaonkar.
Thus was born ARSI, an independent body totally committed to up-lifting the rural surgery.
Since that moment we never looked back. We held our Annual Conferences in nooks and corners of our country even in small towns like our own town (DONDAICHA) where not a single hotel was available. We offered home hospitality to all surgeons and held our conference deliberations in a school building! Participation from many countries including Africa, Germany, Canada, Australia, Bangladesh, Holland, and USA became a regular feature of these conferences unlike the big conferences of Association of Surgeons of India.
Our membership is open to any qualified doctor who does any type of surgery. Besides general surgeons, our members include gynaecologists, orthopaedic surgeons, ENT Surgeons, anaesthetists, physicians & even general practitioners doing surgical work and helping the cause of rural surgery. The scientific presentations & operative demonstrations cover almost all fields of surgery & medicine. This is not possible for any specialised Association or its section which cannot enrol members from other specialities.
Most of the other Associations or Federations of Medical professionals collect handsome fees from their members for the memberships, organise an annual conference in big cities in some five star hotels, arrange some workshops, publish a journal in which usually there are some research papers, case reports and some reviews but no articles dealing with other problems the members face in their day to day working. Same is true for the conferences.
The problems of rural surgeons are entirely different and they can hardly benefit from such conferences.
Usually the rural surgeon after his qualifying examination goes to his village. He has no experience of doing major surgeries on his own neither he has seen procedures from allied fields of surgery like Gynaecology and obstetrics, E.N.T. or Orthopaedics. But in rural practice, besides general surgical procedures he has to do caesarean sections, do hysterectomies, reduce fractures, knock out tonsils, remove urinary calculi and do paediatric surgery. In fact he has to be ‘Jack of All but Master of Surgery’! And therefore, in our conferences we arrange frequent workshops and short training courses of day to day major surgical procedures demonstrated by masters so as to improve in our techniques, and show procedures from allied fields like caesarean sections, internal fixations of simple fractures, plastic surgery procedures, radical mastectomies and similar such procedures. On the contrary if one attends any other conferences one can see that more than 95% of papers, presentations and procedures demonstrated, consist of advance laparoscopic and endoscopic surgeries and robotic surgeries, which are beyond the realm of any rural surgeon.
Besides these common surgical topics our conferences and News-letter deal with other problems of rural surgeons like training of paramedics, setting of hospitals, rural anaesthesia, economics of rural surgery and so on.
The most important aspect of all our conferences is that, they are arranged without any financial help from any pharmaceutical companies or instrument makers, at the same time keeping the registration fees and accommodation charges to minimum, at times giving the delegates free accommodation like home hospitality.
The initial conferences were partly funded by DANIDA, a Dutch organisation, with the help of Dr. J. K. Banerjee. Later when these funds were exhausted, in 1996 Dr. Antia came forward and got a handsome donation of Rs. 5 Lacks from Pirojshah Godrej Foundation, and the interest earned from this was earmarked as conference fund.
Unlike other Associations, ARSI did not restrict its activities to only arranging annual conferences & publishing a bulletin but took keen interest in basic problems faced by rural surgeons like unjust Laws, unavailability of qualified staff, blood transfusion facilities etc.
Many new legislations and laws implemented by the Government are formed by politicians and bureaucrats sitting in the air conditioned rooms of ivory towers in big cities, far away from ground realities faced by the rural surgeons. These laws and amendments are formed for the interest of rich and corporate firms who pay the law makers a hefty sum for their implementations. Many of these laws are unjust and make life miserable for rural surgeons. As an ‘Association’ looking after the welfare of our colleagues, working against all odds, it is our moral duty to fight against such unjust laws collectively.
We are opposing the high & untenable standards led down by the various Clinical establishment Acts and the National Accreditation board for hospitals. We represented ourselves in meetings arranged by National Accreditation Board for Hospitals which wanted to raise the standards of the hospitals to International norms (so that they can attract the foreign nationals for their treatment and their insurance companies can reimburse their claims!) This move would raise the cost of treatment by almost 20 times and would be beyond the reach of 80% of common people with limited earnings, more so of those living in rural areas. No rural surgeon can achieve these standards and if these standards are made compulsory then most of the rural surgeons will have to close down their hospitals.
Representing ARSI, Dr. Tongaonkar, a member of committee formulating the rules and regulations for the newly amended Bombay Nursing Home Act in the state of Maharashtra, reduced the requirements for nurses & space for hospital and many other requirements drastically, to suit the rural nursing homes.
An affidavit by one of us based on the survey done by the Rural Health care Committee stating that 60% of Rural surgeons do not have qualified anaesthetist and at times the surgeons himself gives the anaesthesia to his own patient, helped a rural surgeon settle amicably a claim of Rs. 2.7 million ($ 600,000/-) against him in National Consumer Forum. The surgeon had given spinal anaesthesia to his own patient and was doing hysterectomy himself but the patient unfortunately died and therefore the surgeon was sued for ‘Negligence’.
This is how we as ‘Association’ could help each others.
ARSI was instrumental in amending the central Drugs and Cosmetics Act & brining out concept of ‘The Blood Storage Centre, to meet the demand of blood in rural areas.
Unfortunately our demand for legalising ‘Unbanked Directed Blood Transfusion’ (UDBT) services, where we bleed a voluntary donor after doing all the mandatory tests and transfuse the fresh blood immediately to the needy patient, without keeping it in the refrigerator for a minute. This type of service was legal in India before the new Blood Bank rules came in force in year 1998. Though legally not permissible, even today UDBT ‘is’ in vogue all over our country where authorised Blood Banks are not within the reach especially in rural areas. Therefore, sometimes rural surgeons do come in trouble due to continued use of UDBT. If this happens we do come to their help. We have found out a clause in the Drugs and Cosmetics Act which states that, “No suit, prosecution or other legal proceedings shall lie against any person for anything which is in good faith done or intended to be done under this Act”. Moreover we can also say that this type of service is recommended by World Health Organisation in emergencies and even legalised in India for Military establishments.
To solve the problem of learning new techniques, if any member of our association desires to study in a particular field for a month or so under a renowned teacher he/she is given monitory help through our Shimoga-Jhargram fellowship.
A regular Bulletin or a news-letter is brought out by the Association to report our activities and to present work of rural surgeons. This news-letter is even sent to many countries.
To encourage, appreciate and recognise any pioneer research or use of a new idea which helps the rural health, an Antia-Finseth award of Rs. 10,000/- is given to the deserving persons, may it be developing an indigenous cheap ventilator like Newmom Ventilator or use of 4000 times cheaper mosquito-net cloth for hernia repair.
The use of mosquito-net for hernia mesh needs special mention. After Dr. Brahma Reddy, recipient of Antia-Finseth Award gave a piece of mosquito-net cloth which he was using for hernia repair, thinking it to be ‘Nylon’, to Dr. Tongaonkar in one of the workshops. Dr. Tongaonkar got it analysed and studied its property. To his surprise it turned out to be a co-polymer of Poly-propylene and polyethylene with almost similar properties with that of costly imported poly-propylene mesh.
Dr. Tongaonkar started using it with good results and proper follow- up, and then started popularising it across the country. After three years of its successful use in 6 different centres a paper on this subject was published in the special issue on rural surgery in the Indian Journal of Surgery. After this publication almost 30 centres is India started using this 4000 times cheaper cloth. Later a similar looking cloth was procured which turned out to be ‘Low density Poly-ethylene’ with similar properties. Now it is more than 13 years this cloth is being used in our country with comparable results. After the presentation of a paper on this subject by Dr. Tongaonkar in the 4th International Hernia Congress held in Berlin (Germany) in Nov. 2009, Prof. Andrew Kingsnorth, from Plymouth (U.K.) and the President of European Hernia Society got really interested in this cloth and started using this cloth in many African countries (50 meters of cloth was sent to him as gift by Dr. Tongaonkar). Many Nigerian surgeons including our IFRS secretary Dr. Olyombo started using cloth presented to them by Dr. Tongaonkar during our 3rd International Conference of IFRS at Piplia-Kalan Rajasthan India.
This is one very good example how a low cost technology can be spread across the world and how an Association or a Federation can help their members where-ever they may be!
The third world surgeons can learn from developing but economically backward countries like India by attending our conferences. One concrete example can be quoted. After Dr. Olyombo Awojabi attended one of conferences in Jagannath Puri where he saw a three wheeler auto-rickshaw carrying passengers, he went back to his place and attached a makeshift arrangement to his motor-bike thus producing a low cost ambulance for carrying his patients!
One more very important work done by ARSI is in the field of surgical training. As already written most of the rural surgeons perform surgeries from all the allied specialities. For this they need special training to carry out this task. Therefore with the help of Indira Gandhi National Open University (IGNOU) New Delhi a Certificate Course in Rural Surgery was launched in 1998. For this many booklets were printed which are very useful for a budding rural surgeon. We had to fight Medical Council of India to start this course. The entry point for this course was high, only postgraduates were allowed to take this course therefore this course did not take off successfully. But our long experience in formatting this course helped us a lot in our future venture.
We wanted a course after MBBS (the basic degree in our country for modern medicine (Allopathy) to prepare future rural surgeons who can do life and limb saving surgeries in remote areas of our country therefore we tried hard to start such course on nation-wide basis and now ‘Diplomat National Board Rural Surgery’ (DNB-rural surgery) course is being launched under the Central Ministry of Health, with the help of ARSI.
Besides these activities we regularly publish and circulate our official bulletin with good material and information useful to rural surgeons.
A booklet- ‘Concept of Rural Surgery’ was published, and edited by Dr. J. K. Banerjee by Rural Medicare Society, Delhi.
Dr. Tongaonkar also published his autobiography, ‘Making of a Rural Surgeon’ depicting the life of a rural surgeon in India.
The Chairman-Editor of Indian Journal of Surgery (IJS) Dr. Udwadia brought out a special issue on Rural Surgery in 2003 asking Dr. Prabhu to be the guest editor. There were many articles on various aspects of rural surgery written by many of our members. According to Dr. Udwadia, “that was the best issue ever of the IJS”.
ARSI also is giving fellowship (F.A.R.S.I) to deserving rural surgeons and honorary fellowship to dignitaries helping the cause of rural surgery.
Lastly, not restricting its activity only to India, ARSI wanted to spread the concept of Rural Surgery across the world. It networked with surgical societies of other developing countries and also those of Germany & Holland, our members were invited to participate in their meetings and now ARSI is leading the world by launching International Federation of Rural Surgery, under the able guidance of the 1st president Dr. R. D. Prabhu.
We expect that all such activities enumerated above and carried out by ARSI should be carried out by our International Federation of Rural Surgery so that rural surgeons and people living in remote areas and poor people living in urban slums across the world should benefit from our venture.