Innovating for Surgical Care in India – A Pediatric Surgeon’s Tale of Overcoming Barriers to Care
Dr. Vijay Anand Ismavel is a pediatric surgeon and the Medical Superintendent of Makunda Christian Leprosy & General Hospital, a remote rural mission hospital in the northeast Indian state of Assam. During his two decades of work there, he has helped transformed the hospital from a poor facility that lacked staff and resources into a flourishing medical care facility that to date treats over 90,000 patients and performs more than 2,400 major surgeries annually. Below, Dr. Ismavel tells the story of how he and his wife Ann Miriam, an anesthesiologist, worked to improve surgical care at the hospital, and the challenges they faced along the way.
Makunda Christian was established in 1950 as a leprosy colony by the Baptist Mid-Missions in the United States. Following the Indian government’s decision to ask all expatriate missionaries to leave the country in the 1980’s, the hospital was shut down, and remained closed for 10 years until we arrived there in the early 1990’s. As a Christian doctor, I was aware that Christian medical missionaries had established many pioneering hospitals in poor, remote areas all over the world, which had a transformational impact on surrounding communities. After completing medical school, I knew I wanted to spend my career working in this type of environment, where my work could have the greatest impact in heavily populated, remote areas without medical facilities. Ann Miriam and I arrived in Assam in 1993 to help re-build the hospital, focusing on caring for the poor.
In India, most healthcare expenses are ‘out of pocket’ and a single hospital admission can leave a family or individual in destitution. We wanted Makunda to be a place that offered safe, affordable treatment to poor patients, so we aimed to create an environment that was welcoming and available to all. Doing so, however, was an uphill battle and meant overcoming serious challenges. Our hospital was the only one offering pediatric surgical services in the southern half of northeast India, and we have encountered rare surgical problems, such as patients experiencing problems like primary intra-abdominal pregnancies, abdominal cocoons and complications from gastric surgeries such as jejunogastric intussusception. For many years, basic resources like running water and backup generators were not available, and surgeries had to be performed using simple lighting and sterilization techniques. We had to clean equipment in kerosene autoclaves, tie tissues to control bleeding, use ethers for anesthesia and perform ureterostomies instead of performing fulguration for posterior urethral valves.
We struggled, and it took time for the hospital to develop and grow, but we persevered, employing innovative surgical techniques to overcome the barriers we faced treating patients. For example, we controlled infant birth defects like gastroschisis by using plastic material from a urine drainage bag, and and used choledochoduodenostomy as a routine procedure for bile duct stones. Overtime, the hospital was able to acquire more equipment and recruit and train additional staff. This team of highly committed individuals helped Ann and I turn Makunda into a more robust, effective medical center that includes newer facilities like a blood storage center.
Twenty-two years after we arrived at Makunda, the hospital has been transformed into a high-quality medical center for the poor. Each year, we perform over 2,000 major surgeries and treat nearly 100,000 patients. In addition to helping re-build the hospital, Ann Miriam and I established a higher secondary school, a community college and a nursing home in Tripura. The hospital’s business model works by internal cross-subsidy of large volumes of patients – the patients who are able to pay their bills, subsidizing those who can’t. Overhead expenses remain low because our staff are satisfied with less – they multi-task, live off of lower salaries and work in simpler facilities, although every effort is made to ensure high quality patient care.
Although much progress has been made, there is still work to be done. Throughout many remote parts of India, medical facilities lack adequate resources and medical staff to provide care. In a self-sustaining business model like the one employed by Makunda, we are continually trying to strike a balance between attending to the needs of both our healthcare workers and our patients. We strive to ensure our staff has access to high-quality, effective medical equipment, but acquiring these materials often increases the costs that patients pay for care, and we never want to alienate our poor patients. In addition, Western healthcare standards and protocols are difficult to implement, since they are expensive and not always accessible to the poor (we have developed ‘revised gold-standard’ protocols).
At hospitals like Makunda, innovation is critical for developing affordable medical technologies. For example, we need simple tools that could help salvage ‘clean’ blood from body cavities for auto-transfusion, or an app that could help patients living in remote areas who need emergency care arrive at the hospital safely.
As we have seen through our work at Makunda, affordable technology and business model innovation are critical components for improving surgical care in resource-poor settings. In order to do this, we must work together. Young scientists, entrepreneurs and clinicians must understand the needs of those in low- and middle-income countries so that real, effective solutions can take effect.
Watch this video to learn more about Dr. Ismavel’s work to improve medical care at Makunda Christian.