D. Nageshwar Reddy, Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad 50082, India. Email: email@example.com
In spite of the economic development through the past six decades post-independence, nearly 70% of the Indian population still live in villages, and these people very often have limited access to the advanced health-care technology. In an attempt to render cost-effective gastrointestinal care to the rural dwellers, we have initiated a Rural Health Care Project. We have tailor-made and converted a bus into a mobile hospital equipped with basic diagnostic facilities including a custom-made endoscopy unit. This bus travels to rural areas and renders basic diagnostic and therapeutic services including endoscopy. A telemedicine van accompanies the mobile hospital and endoscopy unit and transmits all procedures and data to the main telemedicine center at our parent institute. We have so far performed over 30 000 endoscopic procedures in 4837 villages with a population of over 10 million people. Both the rural dwellers and the staff involved in this project have reported a high level of satisfaction. This project runs on philanthropic donations.
In spite of the rapid strides in economic development through the past six decades post-independence, nearly 70% of the Indian population are still rural dwellers.1 Advanced health-care systems and technologies are concentrated in the urban regions and there is a huge urban–rural divide in the availability of health-care facilities, including doctors.2,3 Nearly a third of India's population live under the poverty line4 and rural dwellers by and large have limited access to advanced diagnostic and clinical services. Despite the various health-care-related programs of the government, over 40% of rural mortality in India is related to communicable, maternal, perinatal and nutritional diseases.5 In addition, there are other contributing factors like inadequate sanitation, improper water supply and open drainage systems without scientifically designed terminal outlets. We therefore felt that it is also the responsibility of non-government and advanced health-care organizations to extend optimal health-care services to the rural masses. This prompted us to embark on our initiative as the Rural Health Care Project under the supervision of our charitable trust Asian Healthcare Foundation.
HOW DID WE BEGIN?
We began our Rural Health Care Project with a vision to improve the rural health and living conditions by providing free clinical, diagnostic and therapeutic services to the needy villagers of the south Indian state of Andhra Pradesh (AP) where our institute is situated. AP is divided into 23 districts that homes 4837 villages with a population of nearly 80 million people. The project, which began in 2006, started in a bus converted into a mobile hospital equipped with an upper gastrointestinal endoscopy and colonoscopy unit, a transabdominal ultrasound machine, an emergent resuscitation unit and basic sample collection facilities travels to the designated rural areas.
Currently, we have three such buses that operate 25 days a month. These buses are accompanied by a team of dedicated physicians, endoscopists and technicians. Besides this, a van containing a mobile telemedicine unit follows the bus (Fig. 1) and transmits data and the procedures to the main telemedicine unit in our parent institute at a bandwidth of 512 kbps. Our team spends 3 days in a designated rural area and performs the entire exercise in a phased manner in tandem with the local village administration. On the first day, medical graduates, under the supervision of medical registrars and senior physicians, conduct base camps in neighboring villages in the predetermined areas and screen local villagers for health-related problems and requirement for investigations. On the second day, our specialists provide medical consult to the screened group and schedule procedures like upper gastrointestinal (UGI) endoscopy, colonoscopy and ultrasonography for the next day. Patients scheduled for endoscopic procedures and ultrasonographies are directed to a common location where the mobile hospital is stationed. Once a diagnosis is made after the procedures and laboratory work, free medicines are provided to the patients for the same; and patients with a major illness are assisted to get enrolled in one of the government health-care schemes.
Funding for the project comes from philanthropic donations from health-care, pharmaceutical and information technology industries. Besides this, wealthy families of the rural regions also provide generous financial assistance to run the program in their localities.
THE TAILOR-MADE ENDOSCOPY SUITE
Our mobile hospital consists of separate enclosures for the endoscopy unit, transabdominal ultrasonography facility and the basic laboratory facility. The endoscopy unit is custom-made to match a simple but modern endoscopy room with the basic infrastructure. The bus is modified with the capability to draw power from external sources, and also has a battery powered inverter and a servo stabilizer to supply energy for the procedures. Oxygen and compressed air is provided by externally loaded oxygen cylinders and a suction apparatus. The bus also has a constant water supply from an inbuilt water tank with a sink with hands-free powered tap.
The endoscopies are conducted unsedated (Fig. 2) and the instruments are cleaned manually as per standard guidelines.
WHAT DID WE LEARN FROM THE ENDOSCOPIC PROCEDURES?
So far, we have performed nearly 32 756 endoscopic procedures in a population of over 10 million people spanning across 4837 villages. Over 70% of these people had a positive finding on UGI endoscopy and the majority of findings were related to peptic ulcer disease. Helicobacter pylori was positive on endoscopic rapid urease test in 81% of these patients. This was similar to the distribution of H. pylori among people with a negative endoscopy, thereby suggesting that H. pylori is commensal in this population. The prevalence of gastroesophageal reflux-related findings and Barrett's esophagus on UGI endoscopy was very low. While the prevalence of colonic polyps and inflammatory bowel disease were also very low; that of infective colitis (amebic colitis, tuberculosis) was high on colonoscopy.
There was a high level of acceptance and immense satisfaction among the target population and the entire exercise turned out to be a cost-effective health-care service. Besides the target population, a high level of satisfaction was also expressed by the health-care personnel involved in this project.
Our project was a novel initiative in rural health-care among impoverished remote dwellers and was accompanied by diverse problems. The most common hurdles that we faced were: (i) poor connectivity to several remote areas due to bad or even absent roads and availability of only water transport (Fig. 3); (ii) frequent power cuts, that led to extra use of our mobile generators for power supply; and (iii) suspicion and lack of trust in modern medicine, especially among tribal populations, who are more accustomed to their local and indigenous treatment methods. We required the help of non-government organizations and local village heads to convince the people of our motives.
Our Rural Health Care Project over the past 5 years has clearly affirmed that endoscopy can be made mobile and be taken out of the endoscopy suite to serve health-care deprived impoverished rural dwellers. In the near future, it could even be possible to add new technologies like image enhanced endoscopy and perform advanced therapeutic procedures like endoscopic mucosal resection in the mobile endoscopy units.
Our ultimate goal is to cover the whole of India in a phased manner; to our satisfaction, the northeastern state of Sikkim has already started our model of rural health-care. In conclusion, we believe that the concept of the mobile hospital is an effective way to get endoscopic services to remote areas in the developing countries in order to render efficient, satisfactory and cost-effective gastrointestinal health care with easy accessibility.
We would like to acknowledge Dr T. Radha Krishnamurthy and U. Satyanarayana, leader and manager of the program respectively, along with all others who worked passionately in the rural health-care program.