Better

by Atul Gawande

  In the clinic one ordinary morning, I accompanied Dr. Ashish Motewar, a general surgeon in his late thirties on duty that day. He had a black Tom Selleck mustache, khaki pants, a blue oxford shirt open at the neck. He did not wear a white coat. His only equipment was a pen, his thin, almost delicate fingers, and his wits.

  The clinics at Nanded were like those I found elsewhere in India. They were ovens in the heat of the summer. The paint flaked off the walls in jagged strips. The sinks were stained brown and the faucets didn't work. Each room had a metal desk, some chairs, a whirring ceiling fan, torn squares of blank paper under a stone for writing prescriptions, and at any given moment four, six, sometimes eight patients jockeying for attention. Examinations took place behind a thin rag curtain with gaping tears in it.

  In one hour, Motewar saw a sixty-year-old farmer complaining of weight loss, loose bowel movements, and a left-upper-quadrant abdominal mass; a teenage boy with a hot, swollen abscess above his belly button, where he'd been knifed; and three people with right-upper-quadrant pain, two of whom had confirmed gallstones, according to the ultrasound reports they brought with them. A bashful thirty-one-year-old auto-rickshaw driver came in with a walnut-sized tumor growing in his jaw. A turbaned, limping seventy-year-old man dropped his trousers to reveal an aching, incarcerated hernia in his right groin. A father brought his seven-year-old boy in with what turned out to be a rectal prolapse. A silent, scared woman in her thirties undid her sari and uncovered a cancer the size of a child's fist growing into the skin of her breast.

  In total, Motewar saw thirty-six patients in three hours that morning. But he was calm despite the chaos. He would smooth down his mustache with his thumb and forefinger and peer silently over his nose at the papers people thrust before him. Then he would speak in a slow and quiet way that made one listen carefully to hear him. He could be brusque at times. But he did what he could to give everyone at least a few moments of individual attention.

  With no time for a complete exam, a good history, or explanations, he relied mainly on a quick, finely honed clinical judgment. He sent a few patients out for X-rays and lab tests. The rest he diagnosed on the spot. He summoned a resident to drain the teenager's abscess in an adjacent procedure room. He instructed another resident to schedule the patients with gallstones and the hernia for surgery. A woman with diarrhea and abdominal pain he sent home with medication for worms.

  I was especially struck by his treatment of the woman with the eroding breast cancer. Before arriving in India, I had assumed that the complex, expensive treatment such advanced cancers require--chemotherapy, radiation, surgery--would be beyond the system's capabilities and that doctors would simply send patients like her home to die. But the surgeon did no such thing. It was unacceptable. Instead, he admitted the woman directly to the hospital and started her on chemotherapy that same afternoon himself. As a surgeon, I have no idea how to safely administer chemotherapies. In the West, this is something considered so difficult only oncologists know how to do it. But Indian manufacturers produce cheap (often pirated) versions of most drugs, and everywhere I went in India, surgeons had learned how to dose and administer the cyclophosphamide, methotrexate, and fluorouracil themselves, in makeshift treatment rooms of benches and folding chairs. They made compromises out of necessity. They did not monitor blood counts for complications the way we do in richer countries. They gave the drugs through peripheral IVs in patients' arms rather through the expensive central venous lines we use to protect patient's veins from the caustic drugs. But they got the patients through. The same was true for the radiation the patients needed. If they had a working cobalt-60 unit, the kind of radiation therapy unit used in the United States in the 1950s, the surgeons planned and delivered the radiation themselves. If the tumor responded, they then performed surgery. It was textbook treatment devised by other means.

  There was, I soon realized, nothing especially exotic about the troubles most people came to the surgeons with, and this in itself was revealing. In the cottage hospital outside my father's village, half the patients were admitted for diseases we do not often see in the West--waterborne diarrhea, tuberculosis, malaria--but it is unusual for them to die from such illnesses. Primary care has improved considerably, and living standards have too. The average life span of Indians has increased from thirty-two years a few decades ago to sixty-five years today. (Two of my aunts were 87 and 92 when I visited and still able to walk their fields. My grandfather finally died at 110 years of age--he fell off a bus and developed a cerebral hemorrhage.) People continue to get cholera and amoebiasis, but they recover. And then they face what we face--gallbladder problems, cancer, hernias, car-crash injuries. The number one cause of death in India is now coronary artery disease, not respiratory infections or diarrheal illness. And most people, even the illiterate, know that medicine can help them survive the "new" afflictions.

  The health care system, however, was not built to manage such illnesses--it was designed primarily for infectious disease. The Indian government's annual health care budget of just four dollars per person is woefully little for infectious disease--and impossibly inadequate for something like a heart attack. Improving nutrition, immunization, and sanitation remains a deserved priority. Yet the tide of people needing surgery and other kinds of specialized care does not stop. At least 50 of the 250-some patients seen by the surgeons in Nanded that morning turned out to need an operation. The hospital had operating rooms and staff, however, for only fifteen such operations per day. Everyone else had to wait.

  This was the case everywhere I traveled. I spent three weeks as a visiting surgeon at Delhi's All-India Institute of Medical Sciences. Delhi is a spacious and rich city by Indian standards--with broadband, ATMs, malls, and Hondas and Toyotas jostling with the cows and rickshaws on the six-lane asphalt roads. AIIMS is among the country's best-funded, best-staffed public hospitals. Yet even it had a waiting list for essential operations. One day, I accompanied the senior resident charged with supervising the list, kept in a hardbound appointment book. He hated the job. The book recorded the names of four hundred patients awaiting surgery by one of the three faculty surgeons on his team. He was scheduling operations as long as six months in the future. He tried to give patients with cancer the first priority, he told me, but people were constantly accosting him with letters from ministers, employers, and elected officials insisting that he move their cases up in the schedule. By necessity, he accommodated them--and pushed the least connected ever further back in the queue.

  The hospital in Nanded did not have anything as formal as a waiting list. The surgeons simply admitted the patients with the most pressing cases and took them to surgery as space and resources became available. As a result, the three surgical wards overflowed with patients. Each ward had sixty metal cots lined up in rows. Some patients had to double up or take a place between the beds on the grimy floor. One day in the men's ward, three beds held an old man recovering from a repair of his strangulated umbilical hernia, a young man who had undergone midnight surgery for a perforated ulcer, and a bespectacled fifty-year-old Sikh waiting, as he had been for the previous week, to have a large inflammatory cyst of the pancreas drained. Across from them, on the floor, a man in his seventies crouched patiently, awaiting resection of his bleeding rectal cancer. Two men nearby shared a bed: a pedestrian who had been hit by a car and a farmer who had been catheterized because of a large stone obstructing his bladder. The surgeons took them as they could, operating through the day and then rotating duty to continue through the night.

  In doing this, the surgeons were up against more than just the number of patients. Everywhere, they lacked essential resources. And they lacked the basic systems that we in the West can usually count on to be able to do our jobs.

  I am still disgusted by the night I saw a thirty-five-year-old man die from a perfectly treatable lung collapse. He had come to the emergency room at a large city hospital I'd visited. I don't know how long he had waited to be seen. But when I ac
companied the surgical resident who was handed his referral slip, we found him sitting up on a bare cot, holding his knees, taking forty breaths a minute, his eyes full of fear. His chest X-ray showed a massive fluid collection in his left chest, obliterating his lung and pushing his heart and trachea to the right. His pulse was rapid. His jugular veins were bulging. He needed immediate chest drainage to let the fluid out and allow his lung to reexpand. Organizing this simple procedure, however, proved to be beyond our capacity.

  The resident tried draining the fluid with a needle, but the fluid was infected and too thick for the needle. We needed to put in a chest tube. But chest tubes--cheap and basic implements--were out of stock. So the resident handed the man's brother a prescription for one, and he ran out into the sweltering night to find a medical store that could supply it. Unbelievably, ten minutes later he came back with one in hand, a 28 French straight chest tube, exactly what we needed. Shortages of supplies are so common that around any hospital in India you will find rows of ramshackle stands with vendors selling everything from medications to pacemakers.

  When we got the patient moved to a procedure room to put in the chest tube, however, no one could locate an instrument set with a knife. The resident ran to find a nurse. And by this time, I was doing chest compressions. The man was without a pulse or respirations for at least ten minutes before the resident could finally put a scalpel between his ribs and let the pus shoot out. It made no difference. The man was dead.

  Scarce resources were clearly partly to blame. This was a hospital of one thousand beds, but it had no chest tubes, no pulse oximeters, no cardiac monitors, no ability to measure blood gases. Public hospitals are supposed to be free for patients, but because of inadequate supplies, doctors must routinely ask patients to obtain their own drugs, tubes, tests, mesh for hernia repairs, staplers, suture material. In one rural hospital, I met a pale, eighty-year-old man who'd come twenty miles by bus and on foot to see a doctor about rectal bleeding from an anal mass, only to be sent right back out because the hospital had no gloves or lubricating gel to allow the doctor to provide an examination. A prescription was written, and two hours later the man hobbled back in, clutching both.

  Such problems reflect more than a lack of money, however. In the same hospital where I saw the thirty-five-year-old man die--where basic equipment was lacking, the emergency ward had just two nurses, and filth was everywhere you stepped--there was a brand-new spiral CT scanner and a gorgeous angiography facility that must have cost tens of thousands of dollars to build. More than one doctor told me that it was easier to get a new MRI machine than to maintain basic supplies and hygiene. Such machines have become the symbols of modern medicine, but to view them this way is to misunderstand the nature of medicine's success. Having a machine is not the cure; understanding the ordinary, mundane details that must go right for each particular problem is. India's health system is facing the fundamental and mammoth difficulty of adapting to its population's new and suddenly more complicated range of illnesses. And what's required is rational, reliable organization as much as resources. For surgeons in India, both are in short supply.

  This situation is not unique to India, and that is what makes it a core conundrum for our time. Throughout the East, demographics are changing swiftly. In Pakistan, Mongolia, and Papua New Guinea, the average life expectancy has risen to over sixty years. In Sri Lanka, Vietnam, Indonesia, and China, it is more than seventy years. (By contrast, because of AIDS, the expected life span in much of Africa remains under fifty years.) As a result, rates of cancer, traffic accidents, and problems like diabetes and gallstones are exploding worldwide. Cardiac disease has become the globe's leading killer. New laboratory science is not the key to saving lives. The infant science of improving performance--of implementing our existing know-how--is. Nowhere, though, have governments recognized this. A surgeon in much of the world therefore stands on his own, with little more than a pen, his fine fingers, and his wits, to cope with a system that barely works and an ever-growing sea of patients.

  These realities are without question demoralizing. The medical community in India has mostly resigned itself to current conditions. All the surgical residents I met hoped to go into the cash-only private sector (where patients with the means increasingly seek care, given the failure of the public system) or abroad when they finished their training--as I think I would, in their shoes. Many attending surgeons were plotting their escape, too. Meanwhile, all live with compromises in the care they give that they cannot bear to tolerate.

  YET, DESPITE THE conditions, the surgeons have persisted in developing abilities that were a marvel to witness. I had gone there thinking that, as an American-trained surgeon, I might have a thing or two I could teach them. But the abilities of an average Indian surgeon outstripped those of any Western surgeon I know.

  "What is your preferred technique for removing bladder stones?" one surgeon in the city of Nagpur asked me.

  "My technique is to call a urologist," I said.

  On rounds in Nanded with a staff surgeon one afternoon, I saw patients he'd successfully treated for prostate obstruction, diverticulitis of the colon, a tubercular abscess of the chest, a groin hernia, a thyroid goiter, gallbladder disease, a liver cyst, appendicitis, a staghorn stone in the kidney, and a cancer of the right hand--as well as an infant boy born without an anus in whom he'd done a perfect reconstruction. Using just textbooks and advice from one another, the surgeons at this ordinary district hospital in India had developed an astonishing range of expertise.

  What explains this? There was much the surgeons had no control over: the overwhelming flow of patients, the poverty, the lack of supplies. But where they had control--their skills, for example--these doctors sought betterment. They understood themselves to be part of a larger world of medical knowledge and accomplishment. Moreover, they believed they could measure up in it. This was partly, I think, a function of the Nanded surgeons' camaraderie as a group. Each day I was there, the surgeons found time between cases to take a brief late-afternoon break at a cafe across the street from the hospital. For fifteen or thirty minutes, they drank chai and swapped stories about their cases of the day--what they had done and how. Just this interaction seemed to prod them to aim higher than merely getting through the day. They came to feel they could do anything they set their minds to. Indeed, they believed not only that they were part of the larger world but also that they could contribute to it.

  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 f
ar 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.

  True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them.

  Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

  THERE WAS A one-year-old boy I saw brought into the teeming Nanded surgery clinic by his parents, their faces wearing that distressing look of fear, helplessness, and fervent hope I'd come to recognize in poor, overcrowded hospitals. The child lay in the cradle of his mother's arms disturbingly quiet, his eyes open but without interest or reaction. His breathing was steady and unlabored yet unnaturally fast--as if a pump inside him were set at the wrong speed. The mother described repeated bouts of frighteningly violent vomiting--the emesis could burst out of him across a table. A doctor in the pediatric clinic had noted his head to be enlarged, with a circumference distinctly out of proportion to his small body, and made a provisional diagnosis that was confirmed on a skull X-ray: the boy had a severe hydrocephalus--a congenital disease in which the normal drainage of the brain is blocked. The cerebral fluid slowly accumulates, gradually expanding the skull but also compressing the brain to relieve the pressure. Unless surgery is performed to provide a new route out of the brain and skull for the fluid, the resulting brain damage becomes severe, advancing from vomiting to visual loss to sleepiness, coma, and finally death. But if surgery were successfully done, the child could live completely normally. The pediatricians had therefore sent the child and his parents to the surgery clinic.