India Needs Pediatric Surgeons in Every District

Pediatric surgery was born not only out of the need but also the penchant for serving children.[1] In 1917, when a tragedy struck in Halifax, Canada, William E. Ladd, a famous American Gynecologist, sought a crucial career change and laid the foundations of modern pediatric surgery. “The Children’s was (my) very first and most permanent love. As soon as it became feasible after the First World War, I devoted myself exclusively to pediatric surgery and have never regretted it,” Ladd wrote.[2] The central theme of pediatric surgery was the principle of “first call for children.” It implied that children ought to have the highest priority on resources of societies. It was felt that one should encourage every measure that would contribute to the best available care for children first. The sentiment of Sir Denis Browne, “the aim of pediatric surgery is to set a standard, not to seek a monopoly,” was indeed an embodiment of this principle. Pediatric surgery in India has grown manyfold over the years in many aspects. The survival rates have improved for even the most difficult newborn problems such as esophageal atresia and diaphragmatic hernia. Advances in technology such as laparoscopic surgery or robotics have been imbibed very well by the young pediatric surgeons all over India. However, whether the access to pediatric surgeons is there in all districts for Indian children is the biggest question mark. Gandhi[3] in 1970 shared his thoughts on the past, present, and future of pediatric surgery in India. He envisaged a universal access of pediatric surgery to all. In 1974, Upadhyaya[4] wrote on the first decade of pediatric surgical training in India. As a visionary, he mentioned, as early as 50 years ago, regarding the need to create a section or department of pediatric surgery in each medical college of the country. Gupta et al.[5] in 2002 reported that the mean (range) of annual neonatal admissions in neonatal surgical units was 137 (42–263). The mean of newborn admissions requiring surgical intervention per surgeon per year was 36 (17–80). “Whereas in the west Paediatric surgery has made a galloping progress, in India it is still crawling on its knees,” wrote Anurag Krishna.[6] While the number of trainees has increased several times, utilization of this expert pool is abysmal.[6] He wrote that over the years, a peculiar situation had emerged. Despite the ever-growing need of pediatric surgical units in the country, they were not coming up as fast as they should. Despite the availability of a new generation of highly qualified surgeons and equally well-trained supporting staff, they do not have the avenues for their proper absorption and utilization. The net result is a brain drain. “Many are forced to look for openings abroad; or they find no alternative but to settle in a lesser role not commensurate with their specialty expertise,” he lamented.[6] Two decades down the line, the situation has not changed much. The more worrying concern is about the kids in the remote areas who are deprived of the proper and necessary pediatric surgical care they deserve, despite having adequate number of pediatric surgeons in the country. Children are not miniature adults, and a simple dose adjustment is not enough. Pediatric anesthesia and intensive care are unique, and the same applies to pediatric surgery. Adult specialty training does not make one competent to take care of newborns and toddlers who have a unique spectrum of diseases such as pyloric stenosis, malrotation, imperforate anus, and hypospadias. Like pediatrics, the field of pediatric surgery also has a huge spectrum. It extends from demanding neonatal surgical conditions such as necrotizing enterocolitis to complex reconstructions such as cloaca, exstrophy/epispadias, and bladder augmentation.[7] While the need for pediatricians is well accepted even in remote areas, the essential need for pediatric surgeons has not yet been appreciated. So far, in our country, the emphasis has been on increasing the number of training centers for pediatric surgery. No doubt, we must continue to train more surgeons, but what we truly need is to provide these trained surgeons with a basic infrastructure of minimum facilities to cover a larger population. It would appear more logical if the thrust would shift toward service-oriented units. The pressing need for creation of a unit or department of pediatric surgery in each medical college of the country was stressed in 1974,[4] 1992,[6] and 2020[8] by various senior pediatric surgeons in the same editorial section. It is unfortunate that even in 2023–2024, we are making the same demand. It would only be appropriate if pediatricians demand the services of a dedicated, qualified pediatric surgeon for the surgical care of their babies. Gangopadhyay[8] mentioned that many trained pediatric surgeons wanted to stay in bigger cities leading to a disproportionate increase of pediatric surgeons in major cities, leaving an expert crunch in districts. He mentioned that the creation of pediatric surgical posts in smaller cities will not only address the financial security of the many newly passed pediatric surgery trainees but will also ensure the availability of cost-effective treatment options for patients in their proximity. Our present government has promised one medical college in each district not only to improve training but also to provide the necessary services. I bet each district will soon have a pediatric unit. How can the pediatric unit be complete without the help of a pediatric surgeon? Where would the team of pediatricians at district hospitals/medical colleges refer all their surgical cases to? Don’t these kids deserve the delicate surgical hands of a trained pediatric surgeon? Recently, the National Medical Commission in their medical education board circular (U.11022/3/2023-UGMED) dated June 23, 2023, has mandated that for hospitals with a hundred general surgery beds, at least 10% shall be dedicated to pediatric surgery. They have also stressed the need for pediatric intensive care unit and neonatal intensive care unit to cater to the children. I, therefore, insist on the present government to ensure that each district hospital/medical college has a pediatric surgical unit, which may be under the ambit of the general surgery department to ensure the necessary pediatric surgical care for our young citizens. This demand has been echoing over the past 50 years, and it is high time to act on it to safeguard the interests of our pediatric patients.

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