Better (26 page)

So how many women get their mammograms annually? Over five years, one woman in seven does; over ten years, just one in sixteen. The reasons are various. Women themselves are often blamed, but the important underlying factors include how time-consuming, uncomfortable, and difficult it usually is to get a mammogram, how inconvenient the facilities often are, how expensive mammography is for those without insurance coverage, and how rarely reminders are given. The United States government and private foundations spend close to a billion dollars a year on research for discovery of new treatments in breast cancer, but little on innovations to improve the ease of and access to mammography screening.
Nonetheless, studies consistently show that more regular use of this one technology alone would reduce deaths from breast cancer by one-third. This is just one example of what improving performance in medicine could achieve.

I did not completely fathom the full breadth of the possibilities, however, until I considered the practice of medicine in most of the rest of the would--where the best hope for saving lives lies in raising performance, not in expanding genetics research. In 2003, I had just finished my surgical training, and before starting my practice in earnest, I decided to travel as a visiting surgeon to India, my ancestral home. In the course of a two-month tour I worked in a series of six public hospitals across the country--from two-thousand-bed referral centers to rural cottage hospitals and ordinary general hospitals--usually one or two weeks at time.

One of the hospitals I visited was the district hospital that serves Uti, the village my father comes from. Uti is four hundred miles east of Mumbai in the state of Maharashtra and directly north of Karnataka, where I witnessed the polio mop-up. Most of my father's family is still there. He is one of thirteen brothers and sisters. They are farmers. Sugarcane, cotton, and a type of wheat called
jowar
are their cash crops. Drip irrigation has allowed them two crops a year and, along with the money my father sends, that has provided them with a degree of prosperity. Uti has a paved road and electricity. A few houses have running water. Malnutrition is no longer an issue. If the villagers get sick or need a checkup, there is a primary health center with a doctor who comes once a week or so. If they have malaria or a diarrheal illness, he sends them to the cottage hospital in Umarkhed, the small town nearby.
Anything more serious and he sends them to the district hospital in Nanded, seventy miles away. This is where my cousin went with his kidney stones.

The Nanded hospital, however, is the lone public hospital serving a district of 1,400 villages like Uti, a population of 2.3 million people. It has five hundred beds, three main operating rooms, and, I found when I visited, just nine general surgeons. (Imagine Kansas with just nine surgeons.) Its two main buildings are four stories high and made of cement and beige stucco. The surgeons arrive each morning to a crush of several hundred people pressing their way into the outpatient clinics. At least two hundred of them are there for the surgery clinic. The inpatient surgical wards are already full. Calls to consult on patients on other services seem never to cease. And the puzzle to me was: How do they do it? How do the surgeons possibly take care of all the hernias and tumors, the appendicitis cases and kidney stones--and manage to sleep, live, survive themselves?

In the clinic one ordinary morning, I accompanied Dr. Ashish Motewar, a general surgeon in his late thirties on duty that day. He had a black Tom Selleck mustache, khaki pants, a blue oxford shirt open at the neck. He did not wear a white coat. His only equipment was a pen, his thin, almost delicate fingers, and his wits.

The clinics at Nanded were like those I found elsewhere in India. They were ovens in the heat of the summer. The paint flaked off the walls in jagged strips. The sinks were stained brown and the faucets didn't work. Each room had a metal desk, some chairs, a whirring ceiling fan, torn squares of blank paper under a stone for writing prescriptions, and at any
given moment four, six, sometimes eight patients jockeying for attention. Examinations took place behind a thin rag curtain with gaping tears in it.

In one hour, Motewar saw a sixty-year-old farmer complaining of weight loss, loose bowel movements, and a left-upper-quadrant abdominal mass; a teenage boy with a hot, swollen abscess above his belly button, where he'd been knifed; and three people with right-upper-quadrant pain, two of whom had confirmed gallstones, according to the ultrasound reports they brought with them. A bashful thirty-one-year-old auto-rickshaw driver came in with a walnut-sized tumor growing in his jaw. A turbaned, limping seventy-year-old man dropped his trousers to reveal an aching, incarcerated hernia in his right groin. A father brought his seven-year-old boy in with what turned out to be a rectal prolapse. A silent, scared woman in her thirties undid her sari and uncovered a cancer the size of a child's fist growing into the skin of her breast.

In total, Motewar saw thirty-six patients in three hours that morning. But he was calm despite the chaos. He would smooth down his mustache with his thumb and forefinger and peer silently over his nose at the papers people thrust before him. Then he would speak in a slow and quiet way that made one listen carefully to hear him. He could be brusque at times. But he did what he could to give everyone at least a few moments of individual attention.

With no time for a complete exam, a good history, or explanations, he relied mainly on a quick, finely honed clinical judgment. He sent a few patients out for X-rays and lab tests. The rest he diagnosed on the spot. He summoned a resident
to drain the teenager's abscess in an adjacent procedure room. He instructed another resident to schedule the patients with gallstones and the hernia for surgery. A woman with diarrhea and abdominal pain he sent home with medication for worms.

I was especially struck by his treatment of the woman with the eroding breast cancer. Before arriving in India, I had assumed that the complex, expensive treatment such advanced cancers require--chemotherapy, radiation, surgery--would be beyond the system's capabilities and that doctors would simply send patients like her home to die. But the surgeon did no such thing. It was unacceptable. Instead, he admitted the woman directly to the hospital and started her on chemotherapy that same afternoon himself. As a surgeon, I have no idea how to safely administer chemotherapies. In the West, this is something considered so difficult only oncologists know how to do it. But Indian manufacturers produce cheap (often pirated) versions of most drugs, and everywhere I went in India, surgeons had learned how to dose and administer the cyclophosphamide, methotrexate, and fluorouracil themselves, in makeshift treatment rooms of benches and folding chairs. They made compromises out of necessity. They did not monitor blood counts for complications the way we do in richer countries. They gave the drugs through peripheral IVs in patients' arms rather through the expensive central venous lines we use to protect patient's veins from the caustic drugs. But they got the patients through. The same was true for the radiation the patients needed. If they had a working cobalt-60 unit, the kind of radiation therapy unit used in the United States in the 1950s, the surgeons planned and delivered the radiation themselves. If the tumor responded, they then
performed surgery. It was textbook treatment devised by other means.

There was, I soon realized, nothing especially exotic about the troubles most people came to the surgeons with, and this in itself was revealing. In the cottage hospital outside my father's village, half the patients were admitted for diseases we do not often see in the West--waterborne diarrhea, tuberculosis, malaria--but it is unusual for them to die from such illnesses. Primary care has improved considerably, and living standards have too. The average life span of Indians has increased from thirty-two years a few decades ago to sixty-five years today. (Two of my aunts were 87 and 92 when I visited and still able to walk their fields. My grandfather finally died at 110 years of age--he fell off a bus and developed a cerebral hemorrhage.) People continue to get cholera and amoebiasis, but they recover. And then they face what we face--gallbladder problems, cancer, hernias, car-crash injuries. The number one cause of death in India is now coronary artery disease, not respiratory infections or diarrheal illness. And most people, even the illiterate, know that medicine can help them survive the "new" afflictions.

The health care system, however, was not built to manage such illnesses--it was designed primarily for infectious disease. The Indian government's annual health care budget of just four dollars per person is woefully little for infectious disease--and impossibly inadequate for something like a heart attack. Improving nutrition, immunization, and sanitation remains a deserved priority. Yet the tide of people needing surgery and other kinds of specialized care does not stop. At least 50 of the 250-some patients seen by the surgeons in Nanded
that morning turned out to need an operation. The hospital had operating rooms and staff, however, for only fifteen such operations per day. Everyone else had to wait.

This was the case everywhere I traveled. I spent three weeks as a visiting surgeon at Delhi's All-India Institute of Medical Sciences. Delhi is a spacious and rich city by Indian standards--with broadband, ATMs, malls, and Hondas and Toyotas jostling with the cows and rickshaws on the six-lane asphalt roads. AIIMS is among the country's best-funded, best-staffed public hospitals. Yet even it had a waiting list for essential operations. One day, I accompanied the senior resident charged with supervising the list, kept in a hardbound appointment book. He hated the job. The book recorded the names of four hundred patients awaiting surgery by one of the three faculty surgeons on his team. He was scheduling operations as long as six months in the future. He tried to give patients with cancer the first priority, he told me, but people were constantly accosting him with letters from ministers, employers, and elected officials insisting that he move their cases up in the schedule. By necessity, he accommodated them--and pushed the least connected ever further back in the queue.

The hospital in Nanded did not have anything as formal as a waiting list. The surgeons simply admitted the patients with the most pressing cases and took them to surgery as space and resources became available. As a result, the three surgical wards overflowed with patients. Each ward had sixty metal cots lined up in rows. Some patients had to double up or take a place between the beds on the grimy floor. One day in the men's ward, three beds held an old man recovering from a
repair of his strangulated umbilical hernia, a young man who had undergone midnight surgery for a perforated ulcer, and a bespectacled fifty-year-old Sikh waiting, as he had been for the previous week, to have a large inflammatory cyst of the pancreas drained. Across from them, on the floor, a man in his seventies crouched patiently, awaiting resection of his bleeding rectal cancer. Two men nearby shared a bed: a pedestrian who had been hit by a car and a farmer who had been catheterized because of a large stone obstructing his bladder. The surgeons took them as they could, operating through the day and then rotating duty to continue through the night.

In doing this, the surgeons were up against more than just the number of patients. Everywhere, they lacked essential resources. And they lacked the basic systems that we in the West can usually count on to be able to do our jobs.

I am still disgusted by the night I saw a thirty-five-year-old man die from a perfectly treatable lung collapse. He had come to the emergency room at a large city hospital I'd visited. I don't know how long he had waited to be seen. But when I accompanied the surgical resident who was handed his referral slip, we found him sitting up on a bare cot, holding his knees, taking forty breaths a minute, his eyes full of fear. His chest X-ray showed a massive fluid collection in his left chest, obliterating his lung and pushing his heart and trachea to the right. His pulse was rapid. His jugular veins were bulging. He needed immediate chest drainage to let the fluid out and allow his lung to reexpand. Organizing this simple procedure, however, proved to be beyond our capacity.

The resident tried draining the fluid with a needle, but the fluid was infected and too thick for the needle. We needed
to put in a chest tube. But chest tubes--cheap and basic implements--were out of stock. So the resident handed the man's brother a prescription for one, and he ran out into the sweltering night to find a medical store that could supply it. Unbelievably, ten minutes later he came back with one in hand, a 28 French straight chest tube, exactly what we needed. Shortages of supplies are so common that around any hospital in India you will find rows of ramshackle stands with vendors selling everything from medications to pacemakers.

When we got the patient moved to a procedure room to put in the chest tube, however, no one could locate an instrument set with a knife. The resident ran to find a nurse. And by this time, I was doing chest compressions. The man was without a pulse or respirations for at least ten minutes before the resident could finally put a scalpel between his ribs and let the pus shoot out. It made no difference. The man was dead.

Scarce resources were clearly partly to blame. This was a hospital of one thousand beds, but it had no chest tubes, no pulse oximeters, no cardiac monitors, no ability to measure blood gases. Public hospitals are supposed to be free for patients, but because of inadequate supplies, doctors must routinely ask patients to obtain their own drugs, tubes, tests, mesh for hernia repairs, staplers, suture material. In one rural hospital, I met a pale, eighty-year-old man who'd come twenty miles by bus and on foot to see a doctor about rectal bleeding from an anal mass, only to be sent right back out because the hospital had no gloves or lubricating gel to allow the doctor to provide an examination. A prescription was written, and two hours later the man hobbled back in, clutching both.

Such problems reflect more than a lack of money,
however. In the same hospital where I saw the thirty-five-year-old man die--where basic equipment was lacking, the emergency ward had just two nurses, and filth was everywhere you stepped--there was a brand-new spiral CT scanner and a gorgeous angiography facility that must have cost tens of thousands of dollars to build. More than one doctor told me that it was easier to get a new MRI machine than to maintain basic supplies and hygiene. Such machines have become the symbols of modern medicine, but to view them this way is to misunderstand the nature of medicine's success. Having a machine is not the cure; understanding the ordinary, mundane details that must go right for each particular problem is. India's health system is facing the fundamental and mammoth difficulty of adapting to its population's new and suddenly more complicated range of illnesses. And what's required is rational, reliable organization as much as resources. For surgeons in India, both are in short supply.