ORIGINAL ARTICLE

Surgical Work in Medical Missions: Study in Remote Areas of India

Jesudian Gnanaraj^a and Michael Rhodes^b

^aMBBS, MS, MCh (Urology), FICS, FIAGES, FARSI (Rural Surgery),Director of Medical Services, Surgical Services Initiative, Association of Rural Surgeons of India, SEESHA and Karunya University

^bMA(Cantab),BMBCh(Oxon),MD,FRCS,Associate Professor in Surgery, University of East Anglia, UEA and Chairman, Surgical Services Initiative

Introduction

The first author joined the FMPB at that time, when medical interventions like immunization and oral rehydration therapy were considered a high priority along with health education. Implementation was made much easier when the local population realized that the author could also perform surgical procedures. In 1980, the FMPB was spending about 22% of their entire income for medical work.² This was enough to support 40 full time missionaries, and it was in this context that the SSI was started in the year 2000. Having observed the impact of adding surgical work to medical missions in the 1980s in Gujarat, it has been our long term aim to expand the provision of surgical services. This led to the introduction of the SSI diagnostic camp in 2000, followed by surgical camps in 2002. Our hypothesis was that increasing surgical provision might help reach more remote populations and increase the impact of parallel missionary endeavour.

Methods

The aim of the SSI was to make modern surgical treatment modalities available at an affordable cost and to use the diagnostic and surgical camps as an entry point for evangelical work. The mission or the evangelistic team chose and organized the places for diagnostic camps. Often, these were places where entry to evangelists had become possible because of the medical work. The SSI team was from the mission hospital and often had volunteers who were interested in the work of missions. Mission organizations like FMPB and Operation Mobilization were part of the SSI team. Local Churches organized innovative plans like the “Pig for surgery plan.” In this scheme, the church donated a piglet to the family. When it matured, the family sold the pig and paid for their surgery.

Diagnostic camps

The concept of medical camps organized by the missionaries of FMPB helped them enter new areas in Gujarat and Maharastra. Subsequent to the camps, 14 new churches were planted in the area (see Table 1 and Map 1). A survey conducted at nine churches near the Chinchpada Christian Hospital in Maharashtra on the Gujarat border showed that 7 of 9 founder elders of the church heard the Gospel at the hospital for the first time.³ This survey was carried out by FMPB as part of their expansion program. The survey indicated that hearing the gospel message from the nurses was the most effective means of evangelism. Fifty-three of 78 elders (from the 9 churches) who were interviewed became Christians and church elders after hearing the Gospel from one of the senior nurses at the hospitals. At Chinchpada, the medical camps were followed by surgical camps that undertook surgical procedures at remote villages, sometimes using sunlight for surgical illumination.

In 2000, the local churches in Mizoram, Tripura, Nagaland, and Meghalaya helped organize diagnostic camps in these NE Indian states. A diagnostic camp takes all of the diagnostic facilities usually available at hospitals to remote areas.⁴ This includes an entire laboratory with as many investigations as possible, including the pharmacy and gastroscopy, cystoscopy, and ultrasound examinations. Local churches, social service organizations, or the villages themselves organize these diagnostic camps. In addition, organizations like The Young Mizo’s and Operation Mobilization (OM) have accompanied the hospital teams to these camps. Figure 1 shows a Diagnostic camp at Tripura.

The advantages of this model are:

1. It is a cost-effective model that has worked since 2000. Seventy-five percent of patients requiring surgical intervention were diagnosed for the first time during these camps.
2. It aids missionaries in generating new contacts in the isolated community.
3. Volunteers were able to participate in the work. Volunteers helped to organize and advertise the diagnostic camps, identify those who qualified for concessional treatment, and provide transport to where camps were being held.

Surgical camps

The surgical camps, started in 2002, were located at nearby hospitals or health care facilities. Advanced surgical procedures, endoscopic surgical procedures, and laparoscopic surgical procedures were possible with the set of mobile equipment. Qualified and trained personnel were available at these hospitals. A study showed that more than half of the patients who required surgical intervention for prostate disease received the necessary treatment with this model.⁵ This model also proved financially viable, and funding from external sources was necessary only for capital items. Patients on an average paid only about $100 to 200 for a major surgical procedure.

Advantages of this model are that it is the most cost-effective way of treating many surgical conditions with donations only necessary for capital items. During the last decade, over 3500 patients were able to get modern laparoscopic and over 5000 patients endoscopic surgical treatment at nominal cost. Table 2 gives the cases undertaken at surgical camps to date. In addition to providing low cost surgical care, the visiting team helped to train local doctors and upgrade facilities available at the local hospital. Many rural surgeons from India and from African countries have also benefitted from training during the surgical camps.⁶

Research Work in Rural Areas

Surgical work in rural areas is challenging. There are problems of availability, accessibility, and affordability. Several research projects have been carried out to investigate these problems and their findings are also reported in this paper.

Results

In the 1980s, FMPB organized several Medical Camps in the Dangs district of Gujarat. This helped access to new areas for evangelism. Villages and headmen who were opposed to evangelistic work gave access to medical work because it was perceived as a good thing for the community. Table 1 lists the places where churches were founded following the medical work. Prior to the medical (surgical) work, these places were vehemently opposed to Christian evangelism.

The success of medical and surgical work as a precursor to evangelism in the 1980s led to the formation of SSI in 2000, with surgical camps started in 2002. Table 2 lists the operations undertaken to date as part of this initiative. The impact on the local churches and Christian missions is documented in Table 3.

Research surveys of the rural population showed that 92% of the patients came for surgical procedures after hearing from other patients.⁷ Most of them would not be willing to travel more than 5 kilometers for outpatient clinics while they were willing to travel any distance for elective surgical procedures. Most could afford to pay about 5000 to 10000 rupees for surgical procedures ($100 to $200). Minimally invasive surgery is more relevant to the rural population as many of the patients are the breadwinners for the family and absence from work needs to be kept to a minimum. Research on gasless or lift laparoscopic surgery helped us to make laparoscopic surgery available to the rural patients at a fraction of the cost of regular laparoscopic surgery.^8,9 Low cost monitoring systems developed by the staff and students of Karunya University have made these affordable to many rural hospitals and helped properly monitor postoperative patients.¹⁰

Discussion

Surveys of medical missions all over the world have shown that most missions are in remote areas. Many missionary organizations in India have primary medical care as part of their mission. Our observation was that the involvement of surgical staff made both primary medical care and missionary work easier. It was more cost-effective for mission hospitals to conduct medical and diagnostic camps than for a missionary organization to do it on their own. During the study period (2002 to 2014), missions like FMPB and IEM had doctors working in the mission fields, and their work contributed to development of many new churches in both Gujarat and the states of NE India.

Modern surgical methods, like laparoscopic surgery, attracted patients from villages and helped the entry of the missionaries to villages that were otherwise not willing to let them in. The Surgical Services Initiative, in addition to helping poor and marginalized patients, helped to train junior doctors and facilitated specialists in offering their services and teaching skills. High quality surgical work in remote areas is a financially viable solution. Between 2002 and 2014, no specific funding has been available for such work; however, donations were obtained for capital items for the mission hospital, but all other expenses for the camps were met from income arising from the camps.

No funds or grants were received for this study.