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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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EDITORIAL
Year : 2015  |  Volume : 20  |  Issue : 2  |  Page : 57-59
 

Pediatric surgery in India: Time now for review


Department of Pediatric Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi - 110 029, India

Date of Web Publication17-Feb-2015

Correspondence Address:
Devendra K Gupta
Department of Pediatric Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.151543

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How to cite this article:
Gupta DK. Pediatric surgery in India: Time now for review. J Indian Assoc Pediatr Surg 2015;20:57-9

How to cite this URL:
Gupta DK. Pediatric surgery in India: Time now for review. J Indian Assoc Pediatr Surg [serial online] 2015 [cited 2019 Nov 20];20:57-9. Available from: http://www.jiaps.com/text.asp?2015/20/2/57/151543


The pediatric surgeons deal with the congenital anomalies, trauma, tumors, major surgical infections, antenatal diagnosis and counseling related to various sub specialties such as Pediatric neurosurgery, thoracic, urology, plastic, gastrointestinal, traumatology, oncology, and neonatal surgery including many others belonging to man's land from newborn stage to 14 or sometimes even 18 years of age. Pediatric surgery has not been a high profile specialty in India unlike cardiac, neurosurgery, urology and G I Surgery. Though, this is the specialty that needs a high level of training, precision and in addition a compassion to treat the children who are looking forward at least 60-70 years in life.

The specialty that got its recognition about 5 decades back in India has consolidated its position with over 30 training centers awarding the M.Ch and DNB degrees with 3 year and 6 year programs producing about 100 pediatric surgeons every year. Most centers have engaged good teachers, developed training and infrastructure facilities including the newborn Intensive Care Units (ICUs), endoscopy instruments and the Minimal invasive surgery set up. Conferences and workshops organized in almost all corners of the country are found highly educational and beneficial to promote the specialty. However, the level of training, teaching, research and the expertise gained vary from place to place.

India with over 1.2 billion population now has over 400 million children under 14 years of age. Over 23 million babies are born in India each year and over 6 million die soon after birth. Almost 40% babies are premature and less than 2.5 kg in weight. About 2% babies are born with congenital malformations, of these 0.01% are serious and require urgent surgical intervention if they are to survive. About 1.72 million babies would die each year under 1-year of age in India alone. This presents a huge clinical workload of various surgical disorders to be treated in childhood. The insurance cover is for less than 7% population. Due to paucity of children hospitals and the experts to cater to the need, many childhood disorders continue to be dealt by the adult general surgeons and the urologists.

Some excellent neonatal surgical facilities are available in the government and a few in the private sector. The neonatal surgical ICUs though available remained mostly under staffed and ill equipped, apart from being expensive. Most sick and serious children with major surgical problems have to travel long hours even for short distances to reach the major centers. It is the mode of travel and not the distance that is important. Late presentation especially the patients with large and advanced tumors, prematurity, low birth weight, hypothermia, and infection continue to adversely affect the final outcome in this field. The public sector health care facilities are limited as only 1.2% of the gross domestic product is allocated to the health sector. Even today, of the 360 odd medical colleges in the country, not all of them have developed the facilities for treating children with known surgical diseases. Thus, the outcome remained less than optimal.

Despite the availability and the popularity of ultrasonography, only about 20% anomalies are now detected antenatally and 40%, of these being the genitourinary. The incidence of congenital anomalies has been found higher in a rural population (possibly due to liberal use of pesticides in the fields). Some of these are quite unique to India, e.g., 10% associated pouch colon with high anorectal anomaly. Interestingly, the incidence of appendicitis, gastrochisis, and pyloric stenosis is much less common in Indian population. The parents still respect the advice of the doctors. Thus the medicolegal cases are not so common. Facilities for fetal intervention and organ transplantation are developed only in a few centers. There are not many children Hospitals, trauma centers, and the oncology departments. Endoscopy, minimal invasive surgery and the Sub specialties are mostly individual based. Research labs are also not available in most departments. The treatment modalities are quite often tailored to suit the local conditions, utilizing the available manpower, the infrastructure, and the limited resources. The record keeping and the follow-up record of most children remained variable and unpredictable.

As per Kyoto Declaration of the World Federation of Associations of Pediatric Surgeons in 2002, all the Newborns, infants and children deserve to be treated only by the experienced and the qualified medical personnel. However, there is a global shortage of the competent and trained manpower to treat the pediatric population, resulting in high morbidity and even mortality, especially in the developing world.

The newborns in the developed world is a rarity as the birth rate in the developed world is going down or touching almost zero level, contrary to that in the developing world. Due to this, there is not sufficient volume of the index neonatal surgical cases in several centers in India as well as in the developed world. Thus, many pediatric surgeons from these places prefer to visit the known centers in the developing countries.

There is a need to increase the national health budget to about 2.5%, for improving the training programs, patient safety, antenatal screening, school health care, opening the new children Hospitals, creating the job opportunities for the trained man power, developing the pool of trained doctors, nurses and allied health personnel for the new sub specialties, emphasis on the quality rather than on the quantity and allowing the NRI and even other nationals to work in India in the specialized fields as the world experts to improve the health of the newborns and children. Several rich nations, non-governmental organizations and industrial houses are keen to help in this field to establish "child health care centers" in the developing countries not only to provide quality newborn care, but also to teach and train the next generation of Pediatric surgeons from the countries with limited opportunities. The number of pediatric surgeons being trained each year and the available job opportunities do not match. Shortage of specialists is a myth. Pediatric surgery cannot be established or practiced in isolation in villages. Only the basic problems need to be dealt with at periphery by the one who can deliver the services with good outcome, let it be a general surgeon, a urologist or a pediatric surgeon. The major disorders should be referred to the tertiary care level hospitals. As a team of the pediatric surgeon, the pediatrician, the radiologists, the anesthesiologists and the pathologists is needed for interaction, service and exchange of notes.

The time has come now that teaching departments and the national association should devote more time on the future planning, expansion and projections of the specialty and its sub-specialties at the national and international level. The teaching departments should strive on the quality of the trainees rather than on the quantity, inculcating work ethos and culture, developing uniform standard of teaching and training in the country, trying to fulfill the deficiencies in the available infrastructure required for offering the postgraduate teaching and training programs, developing neonatal surgical ICUs to offer training opportunities to the residents in neonatal monitoring and resuscitation techniques, training in Advanced Trauma Life Support and Pediatric Advanced Life Support, arranging the work ethics, orientation and research methodology courses for all the new ones who join the specialty, involving them in clinical and basic research projects on common problems related to the specialty, rotation of the residents with the pediatric department colleagues, participating in the national and international workshops and the conferences encouraging them to present the scientific work and interact with others so as to remain updated on the subject. Patient record keeping and their follow-up also need to be emphasized.

The district hospitals and even some of the medical colleges do not have the infrastructure to offer the facilities in this field. While India with large volume of children with congenital malformations, trauma and tumors need general pediatric surgeons with adequate training and stress on the competence in neonatal surgery, trauma, and tumors, we do need the specialists and the super specialists in pediatric surgery as well, not to lag behind from the rest of the world. A neonatal surgical-ICU (ICU) set up with 10 beds and at least 3 specialists is considered viable for a population of 1 million population. Thus in India, Delhi alone needs about 20 such NS-ICU set ups. The availability of the neonatal surgeons with experience in fetal surgery, the laparoscopists, the robotic surgeons, the urologists, the traumatologists, the oncologists, the hepatobiliary surgeons, the vascular surgeons, the pediatric neurosurgeons and like that, can only be accomplished in the institutional set up, with the creation of new jobs for the faculty and fellows (in various sub specialties).

The Medical Council of India should work to improve and standardize the teaching programs. The available infrastructure in most health centers remained poor with inadequate staff, equipments, sanitation, and space. The access to primary and advanced health care has remained sub optimal in health care services to a common man even after 66 years of independence.

The Ministry of Health and Family Welfare should review the health policy out of a closed box to think and streamline the management aspects of health centers in the country. Not only the allocation of budget needs to be increased, it is to ensure the speedy implementation of the central and state's health schemes. We have competent man power. Their strength needs to be harnessed. Work autonomy, trust, and the freedom are the key issues for the medical institutions to progress.

The World Federation of Associations of Pediatric surgeons, with over 125 member country associations, is committed to strengthen and improve the health of children around the globe through quality education and awareness. Not only the Government but also the non-governmental support is important to develop facilities in neonatal surgery in Medical colleges and referral centers, especially in the developing world.

 
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