Milestones and Developments in surgery in India since Independence
Editor: S P Kaushik
Publisher: Paras Medical Publisher, Hyderabad
Year 2013. Chapters 19; Pages 173, Price Rs.475/-
ISBN-987-81-8191-386-9
There is an old Australian Aboriginal saying – “People who lose their history, lose their soul”. We must know our past to understand who we are and what we are. The aphorism “the farther back you look, the farther forward you can see” reaffirms this truth. The purpose of Professor Kaushik’s book is to “preserve and protect what the past teaches us”. His intended audience is a generation of young surgeons of today and of the future to whom he has appropriately dedicated this book.
Professor Kaushik is one of the early pioneers of Surgical Gastroenterology and has played a prominent role in the shaping of this super-specialty in India. He has undertaken the Herculean task of documenting events and history as it has unfolded during the past 70 years. He has done a great service by getting together eminent surgeons to document history as it happened yesterday. For any one observer to review this book with numerous chapters on super-specialties and sub-specialties would be a formidable task. My endeavour will be to review the sections on medical education, surgical Gastroenterolgy and Transplantation which are areas of my interest and also to comment on the overview of surgery as documented by the author.
The book has 19 chapters, 11 of them devoted to development of specialties, super-specialties and sub-specialties. The first few chapters narrate the influence of the Western medical system, the contribution of medical missionaries and the Royal College of Surgeons of UK. The author goes on to describe the existing medical bodies, the Indian Medical Association, the Medical council of India and the Association of Surgeons of India and the changes introduced.
Although medical education is regulated by the Medical Council of India (MCI), it has been unable to enforce uniform high standards of surgical training which varies from centre to centre. The National Board of Examinations established in 1975, has elevated the standard of post-graduate medical education by setting high standards of training, a uniform curriculum and system of examination, but suffers from lack of Governmental and peer support. There is reluctance by medical institutions in India to agree to a common curriculum and examination system, one that a national body like the NBE could conduct. The chapter on medical education should also have addressed itself to surgical training. Medical institutions the world over are known by the quality of their training programs. The history of surgery would be incomplete without it. How are surgeons trained in India? Has surgical training kept pace with the explosion of knowledge and advances in technology? Has it evolved from didactic class room teaching to an in service training program? An apprenticeship – Shushruta’s “Gurukul Vasam”? has it inculcated in our trainees compassion, integrity and work ethics? All this needs documentation.
There are typographical errors, omissions and a few factual errors. That Dr Arole began his community health project in 1774 and not 1974 is one such example. His Jamkhed Model has not been replicated anywhere else as is claimed in the book. ‘Any model that relies on highly motivated individuals is not replicable’. The problem with many Christian mission hospitals is that when the highly motivated individuals who started the centres were no more, those who followed lacked the motivation and some were there for vested interests. Nonetheless mission hospitals have not become foot notes of history and continue to make significant contribution to medical education and patient care. They provide medical care in the remotest corners of India. Surprisingly St Stephen’s Hospital, Delhi, does not find a place in the chapter on mission hospitals. Established in 1885 it is one of the largest and oldest hospitals in north India. It has 600 beds, and is a multi-specialty tertiary care hospital, that runs several postgraduate training programs affiliated to the National Board of Examinations (NBE).
Following independence there has been a phenomenal increase in the number of medical colleges both in the government and in the private sector. The corporate sector has now entered the medical profession in a major way. There is no denying that Corporate Hospitals in India, have provided advanced technology and patient care comparable to the best in the world. Unfortunately it has also commercialized medicine and the practice of surgery is “no longer a calling”. Patients are referred to as clients and the profession a medical industry. Corporate hospitals have changed for ever the practice of surgery in India.
Dr Kaushik has traced the development of surgical Gastroenterology in India, which is perhaps the only country in the world to have this super-specialty. The claim that the foundations of surgical gastroenterology were laid in UK is not entirely true, as gastroenterology clubs were dominated by physicians with a ‘committed surgeon’ inducted as a member. Nevertheless an idea was born which never took fruitation in the United Kingdom. Their approach has been to develop colorectal, hepatobilliary, pancreatic, oesophageal and upper GI surgery as separate sub-specialties.
The chapter on Renal Transplantation is well written. The author talks of the Transplantation of Human Organs Act, the absence of a Transplant Registry and the failure of the Cadaver or what is now-referred to as a deceased Donor Transplant Program (DDLT). Most transplants in India are from living donors. The risk to life and post-operative complications for the living kidney donor is small and to an extent acceptable, but this is not so for the living liver donor. There are a few centres of repute providing Living Donor Liver Transplants (LDLT), but this can never provide for the large number of patients requiring transplants. Besides, a zero mortality for a living donor can never be achieved. The way forward is to develop the deceased donor program.
The chapters on Renal and Liver transplantation do not talk about donor promotion organizations, notably the Chennai based Mohan Foundation (Dr Sunil Shroff), and a few others in South India, Maharashtra and Gujarat which are doing a commendable job creating awareness, developing a local network for organ sharing and promoting cadaver organ donation with increasing success. In 2012, a total of 530 organs were retrieved from 196 deceased organ donors resulting in a national donation rate of 0.16 per million population with Tamil Nadu leading with 1.15 per million population (Data from Mohan Foundation). Progress in DDLT is certainly being made. no history of transplantation can be complete without documenting the contribution of these organizations.
“History is made by the deeds and perseverance of individuals”. A second generation of hepatobiliary and transplant surgeons finds no place in the chapter on liver transplantation. V Sitaram, (Christian Medical College, Vellore), R Surendran (Stanly Medical College, Chennai), Anupam Saha (R.R. Hospital, Delhi), H Ramesh (Lakeshore Hospital, Cochin – performed the first liver transplant in Kerala) and Sanjay Govil (Columbia Asia, Bangalore) are among those, who more than anyone else have put liver transplantation on a firm footing in India.
One notable omission is a chapter on Orthopedic surgery. Initially a part of the Association of Surgeons of India it has grown as a major specialty with several sub-specialties in India. I wonder if there should also have been a chapter on General Surgery, as the general surgeon handles the bulk of the burden of emergency surgery in our country.
Despite a “paucity of archival material” the total absence of bibliography is a void that needs correction. None of the contributors have recorded the source of their information, be it from personal communications, letters, net searches or the proceedings and records of various societies and medical bodies.
The book ends abruptly with the chapter on surgical endocrinology. A closing chapter could have provided “a brief introspection on the philosophy of surgery” or on the teachings and the art of surgery in ancient India and why it faded into oblivion.
The book documents a wealth of information – “work that will provide inspiration to posterity” as Prof. Kaushik hopes. A few omissions and corrections can be addressed to in a future reprint or edition. I would strongly recommend this book for all medical libraries in India and those aspiring surgeons for whom it is intended.
Prakash Khanduri
St Stephen’s Hospital, Delhi
