In the Bonesetter's Waiting Room (13 page)

For a person who performed multiple demanding surgeries and would see up to eighty patients over the stretch of an eighteen-hour day, a base designed to provide some comfort and calm must have been vital – but the totems here seemed more significant than that. Shetty's space had a distinct feeling of sacred calm, appropriate to the hospital's Hrudayalaya suffix as a ‘temple' of the heart. That he is proud of and dedicated to working for his country was clear from two national emblems on display in the room – the Indian flag and a model of the Ashoka Pillar that flanked a giant teleconferencing screen.

‘I went to England for training in cardiac surgery,' Dr Shetty told me. ‘In those days such training was not available in India because of the very small volume of operations. [But] I never had plans to settle down in England even though I had very good offers and opportunities. India is my country, this is where I belong and this is where my people need me. I am sure England is not missing me,' he joked.

But what if England was missing him? I knew that Shetty had already entered into partnership with one of the largest non-profit hospital chains in the United States to explore ways of using his model to cut healthcare costs in a country infamous for handing its patients the biggest bills in the world. To build and operate his proposed Cayman Islands healthcare city, the arrangement was for Shetty's group to provide technical input and running of the facility, while the US healthcare alliance group dealt with the purchasing, facilities management and biomedical engineering services. In the UK, massive government ‘austerity' cuts to the healthcare budget coupled with growing migration into London and other urban centres, the stresses of managing an ageing population and staff shortages mean that, as counter-intuitive as it may seem, health systems of even wealthy nations might benefit from the Narayanaya model. Did Shetty agree?

‘I strongly believe that all hospitals should be run as social enterprises. Because our customers are unlike customers of other industries: if they are not served then lives may be lost,' Shetty began. ‘Primary and secondary healthcare [i.e. that provided by GPs and clinics] should be available at doorsteps of the patients. Tertiary healthcare [major operations] should be delivered in large hospitals where hundreds of procedures are done on a daily basis. In this way, the procedures become standardised, mortality and morbidity go down and the cost falls significantly because of economies of scale.'

‘Here we implant one of the largest numbers of heart valves in the world,' he continued, ‘and, in the process, our outcomes are naturally one of the best. Because of the large numbers, we are able to procure materials at a lesser price than other hospitals. Again, because of the large numbers, when the result gets better, more patients come and you enter a virtuous cycle. This is the beauty of numbers.'

The next time I met him was in Manchester, where he was a keynote speaker at the UK's National Health Service health innovation conference. Joining him on the podium were Sir Bruce Keogh, also a cardiologist and medical director of the NHS, and Professor Gillian Leng, deputy chief executive and director of health and social care at the National Institute for Health and Care Excellence (NICE).

Devi described the methods Narayana used to keep costs low and increase efficacy – training local manufacturers to make surgical gowns cheaply rather than buying them in at high prices, for example, thus both reducing costs and providing local employment. He talked about the use of apps by doctors to engage remotely with patients who were unwell but did not need surgical intervention. Many of the doctors working in this way were women who would otherwise not have worked while raising their children. He described using text messages to keep staff informed and how hospital stays could be shortened by training family members to provide basic medical care at home – bathing, changing dressings and even simple physiotherapy.

‘This is the power of not having money,' he told his NHS colleagues. ‘When you have money in the bank, your brain stops working.'

Sir Bruce Keogh and Professor Gillian Leng were in broad agreement. ‘We all have the responsibility to manage funds,' said Leng, while Sir Bruce noted that, when Devi talked about money, he only ever did so in the context of value. ‘The problem in the NHS is that people don't know what things cost. How can we reduce spending if we do not know this?' asked Keogh.

He also believed that putting healthcare online, as Devi has already started to do, will result in a very significant shift towards putting patients in charge of their own healthcare. That, after all, is the direction in which the NHS also needs to head, if it is to continue offering free healthcare to the UK's growing and ageing population.

Shetty came from a very rural area in Mangalore, where the majority of the population work in farming or agriculture, meaning that they earn little but are extremely numerous. His vocation to provide free healthcare for all has clearly been shaped by his upbringing, and in particular by the chronic illnesses by which both his parents were afflicted.

‘I guess that was why I became a doctor. My childhood was spent in fear of losing my mother. My father suffered multiple episodes of diabetic coma. The image we had of God as children was as a healer who could save the lives of our parents,' he said. Perhaps this explained the religious elements prevalent both in his office and in the hospital complex. In any event, this was an interesting thing to hear from a man who was clearly now very much a believer in God and who says that the reason he treats people in need for free is because it ‘is the best way I can repay God, who has given me everything I wanted'.

Dr Shetty continued with his story. ‘One day at school our teacher announced that somebody in South Africa had transplanted a human heart. That statement had a great impact on me. As a kid I was fascinated with the concept of using a dead person's heart to help a living person.'

The event he was referring to was the first ever successful transplantation of a human heart, on 3 December 1967, by South African surgeon Christiaan Barnard. It is hard to imagine now what a ground-breaking moment that must have been – today we think of organ transplantation as a complex, but routine procedure. To the fourteen-year-old Devi Shetty, it was a magical moment.

‘That day I decided to become a heart surgeon. In fact, I decided to become a heart surgeon well before I decided to become a doctor. As a teenager, I did not have the maturity to know that I should become a doctor first before becoming a heart surgeon.'

Of course, even in India today, there are many young people for whom the ambition to become doctors like Shetty is alive and well. Why, then, was there such a desperate dearth of doctors in India today?

‘Outstanding doctors have often come from deprived backgrounds, but myopic medical education policies exclude many potential candidates. Medical education costs far more than it needs to. After all, it is just an apprenticeship. Senior consultants train young registrars and make them great doctors over a period of time. But academics have made medical education so complex and in the process it has become absurdly expensive.'

The extortionate cost of obtaining a medical qualification is understandably causing a great deal of concern to potential students and their parents. True, to enrol at a public university is cheap (the equivalent of around £100 to £300, depending on the level of study) and there are no admission fees. But these courses are massively oversubscribed and competition for them is fierce. The alternative is to enrol at a private medical college, but that might cost upwards of £50,000, and nearly as much again in tuition fees over the course's five-year duration. And that doesn't include the inevitable bribes.

These expenses are unlikely to be recouped in India, where monthly salaries on qualification will only be around £3–400 in the public sector and perhaps double that in the private.

Some doctors find ways to supplement their incomes – by overprescribing medicines, for example, or requesting unnecessary tests. Stories of bribery and corruption are also rife. Of the rest, many leave for better-paid posts abroad as soon as they qualify, and most never return. India's elite All India Institute of Medical Sciences (probably the most competitive and difficult medical school to get into) sees fifty-three per cent of its graduates going abroad. In its cities, India has only around half the number of medical staff per thousand of the population that the World Health Organisation recommends. In the countryside it is worse, but government attempts to fill major care gaps – forced postings to rural areas, for example – have usually been met with protests and strike action: in 2013, nearly 300,000 medical students protested against the Indian Medical Council's ruling to make a year-long rural stint compulsory.

The West's gain through the medical brain-drain is translating into a loss that India cannot afford. The proposed solution is drastic: from 2015, Indian doctors heading abroad for higher medical studies are required to sign a bond with the Ministry of Health & Family Welfare that they will return home either after two years or upon finishing their courses. Those refusing to sign will be denied permission to work abroad. Some medical association representatives have complained that such a stipulation infringes on the basic constitutional rights of Indians. Others question why this scheme should not be applied to Indian engineers, scientists and other Indian-trained professionals as well (although, of course, there is hardly a dearth of those, and their careers do not in general oversee matters of life and death).

The situation may seem bleak at the moment, but in Shetty's eyes there is some hope, should India be able to force disruptive change. ‘We are short of one million doctors, two million nurses and close to three million beds. If you start one hundred medical colleges [a year] for the next five years, that would result in a sufficient number of doctors by 2025.'

Shetty's vision is for a decentralised system of healthcare training, where medical colleges will spring up across the country, in poor and rural areas as well as the big cities. ‘Once they give preference to local students in the medical colleges, a small percentage of them will stay back in their own towns to serve the needs of the local population. This is the only way we can have equitable healthcare in remote locations.'

There are probably not enough qualified trainers in India to realise his vision, but Shetty has a plan for a global partnership to help with that too. Much as Narayana has been able to do for healthcare, Shetty believes that ‘basic policy changes will bring medical education within affordable reach of everyone'.

After leaving Devi Shetty to return to the ceaseless influx of phone calls and paperwork before his day's surgical work began, I headed off with Asha to see how things at Narayana worked in practice. Our first stop was the operating theatres. I was used to the idea of a surgical theatre as a hermetically sealed box, but here I found that, just like Shetty's office, all had large glass frontages with views to the gardens outside, which, the surgeons told me, helped prevent fatigue and the feeling of being closed in over the long hours of concentration that major heart surgery demands.

We visited the paediatric surgeons, one of whom, Shreesha Maiya, had previously worked at London's Great Ormond Street Hospital for fourteen years. I asked him what it was like being back. ‘Here we perform about three thousand paediatric heart surgeries a year,' he told me. ‘When I was at Great Ormond Street we did about five hundred in that time.' Incredibly, Narayana was producing these results with around half the number of staff surgeons as the London children's hospital. When I asked Shreesha how that was possible, his reply was, simply and with conviction, ‘We just have to work a bit harder.'

As Asha and I continued our tour of the health complex on one of the golf buggies used for transport, I took the opportunity to speak to staff in some of its specialist facilities. We talked about heart valve donations and the valve bank the heart hospital had set up to support the thousands of surgeries they performed every year.

On the third floor of the complex's building dedicated to cancer care, I had a chat with Narayana's very friendly head of the Bone Marrow Transplant Unit, Dr Sharat Damodar. We talked about new frontiers in stem-cell science and I was surprised when he told me it was still difficult to get bone-marrow donors – in the West, donors of Asian origin are rare, but this was India. Even so, it sounded like there was still work to do in raising awareness among the public.

Down on the ground floor, a young radiologist, Rajiv Kumar, gave me a tour of their heavy equipment, including the three MRI machines that work until midnight every day to cope with the sheer volume of patients requiring scans. He showed me how he makes transparent plastic masks for patients requiring cranial radiotherapy in order to keep their heads still. I asked him about the types of cancers he sees – far too many, he told me, were related to smoking, or the chewing of tobacco, especially in poorer patients.

The expertise and dedication of everyone I met was impressive, as was their commitment to Devi Shetty's ethos of care. I got a strong sense that the workers here were vocation-driven, and importantly (perhaps because of this), they seemed happy, despite the immense workload that would-be doctors in Europe or America simply never encounter. The workstations of some displayed inspirational quotes or meditations on service and kindness. One postsurgical teenage cancer patient talked and joked with us as we came by. ‘He said he put on his glasses,' Asha translated from his native Kannada, ‘because he saw some good-looking people come into the ward.' As our golf buggy returned to the main hospital, I remarked on the warmth of the atmosphere Devi Shetty had managed to create for patients and staff. He was a very inspirational person – and clearly a spiritual one.

‘He's a living saint,' she replied, entirely sincere. ‘It's not only health and education; he has a wider outlook. See
all
of our drivers – these buggies and the ambulances and many of our security staff – are women. We saw many men doing the same jobs spending their salary on alcohol or something equally useless. Dr Shetty now employs women directly because when they are paid they save the money for their children's education, nutrition, their families, their future.'