After reading this Bloomberg article, Heart Surgery in India for $1,583 Costs $106,385 in U.S., I couldn’t resist thinking about the end of Atul Gawande’s book, “Better: A Surgeon’s Notes on Performance“…cost comparisons to India inevitably bring up discussions along the lines of, “Well, just how good can their health care be?” Certainly, it’s hard to think of apples to apples metrics that would allow us to compare quality of care between the U.S. and India due to selection bias: patients in India who are able to go through heart surgery (and pay for it) may have a different health profile than the average American who undergoes that treatment.
Still, Gawande’s closing chapter in “Better” argues that even in relatively poor conditions, real, industry-changing innovation can occur due to necessity. In this final chapter, Gawande describes spending time in India as a visiting surgeon to see how innovative medical care was possible in comparatively squalid circumstances. The Nanded hospital he describes below serves 1,400 villages, about 2.3 million people, with just 9 surgeons (Gawande says that’d be comparable to the state of Kansas having 9 surgeons):
Among the many distressing things I saw in Nanded, one was the incredible numbers of patients with perforated ulcers. In my eight years of surgical training, I had seen only one patient with an ulcer so severe that the stomach’s acid had eroded a hole in the intestine. But Nanded is in a part of the country where people eat intensely hot chili peppers, and patients arrived almost nightly with the condition, usually in severe pain and going into shock after the hours of delay involved in traveling from their villages.
The only treatment at that point is surgical. A surgeon must take the patient to the operating room urgently, make a slash down the middle of the abdomen, wash out all the bilious and infected fluid, find the hole in the duodenum, and repair it. This is a big and traumatic operation, and often these patients were in no condition to survive it. So Motewar did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcerous perforation, using quarter-inch incisions and taking an average of forty-five minutes.
When I later told colleagues at home about the operation, they were incredulous. It did not seem possible. Motewar, however, had mulled over the ulcer problem off and on for years and became convinced he could devise a better treatment. His department was able to obtain some older laparoscopic equipment inexpensively. An assistant was made personally responsible for keeping it clean and in working order. And over time, Motewar carefully worked out his technique.
I saw him do the operation, and it was elegant and swift. He even did a randomized trial, which he presented at a conference and which revealed the operation to have fewer complications and a far more rapid recovery than the standard procedure. In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.
BTW, I whole-heartedly recommend Gawande’s “Better”, written in 2008. It extends upon his previous work, Checklist Manifesto, which was best known in its New Yorker incarnation.