BHR Dr. Bose in India
Christmas came early for me last year, and my orthopedic
surgeon unwrapped
the bandages covering my gift: a brand new Birmingham Hip
Resurfacing, with
a barely perceptible scar. Made in Britain and installed in
India, my
innovative, bone-sparing prosthetic hip is available
throughout Europe,
Asia, and Canada but not in the United States. "You'd
expressed concern
about the scar, so I used a plastic surgery technique with
subcutaneous,
resorbable stitches to close," explained Vijay C. Bose, a
consultant at
Apollo Specialty Hospital in Chennai. "When it heals, you'll
hardly see it."
Viva Indian health care! It may seem insane to leave the
richest country in
the world to have surgery in one of the world's poorest, but
in the Internet
age, a savvy health-care consumer really can buy the best
for less. India
abounds with humble, compassionate physicians who provide,
via e-mail and
without charge, detailed consultations and accurate price
quotes. At private
hospital cha ins like Apollo, whose corporate goal is to
become "the
healthcare destination of the world," bustling platoons of
"guest relations
specialists" arrange every detail, from airport pickup to
hotel bookings.
For the 46 million Americans lacking health insurance
(including those whose
benefit-bearing jobs have been outsourced abroad), India
represents an
opportunity to leverage their First World dollars into
first-class care. I
paid $5,600 for my new Elvis pelvis. The price included the
surgeon's fee, a
week's hospital stay (including two days of round-the-clock
private
nursing), the prosthesis, all my meals and meds, and a
rather elegant
leg-lengthening procedure to make my legs at long last
perfectly plumb.
I also took advantage of my week "in hospital" to check off
other items on
my medical to-do list. A plastic surgeon excised a fibroma
from my face for
about $100, coordinating this procedure with my orthopedic
surgery so I
wouldn't have to be re-anesthetized. After spending five
years and thousands
of dollars in New York City trying to get a diagnosis for a
recurring sinus
problem (and receiving nothing other than antibiotics,
unnecessary tests and
outrageously padded bills), Babu Manohar, MD, an Apollo ENT,
unraveled the
mystery in minutes. My CT scan there cost $60 (I'd been
given an $1,150
quote by a clinic in New York), and his consult cost $8.
After employing a
fascinating mix of ultra-modern and traditional procedures
to diagnose the
problem, Manohar explained the underlying malfunction (a
kinked septum and
turbinates four times normal
size) and crisply detailed my treatment options: a
new-generation nasal
spray (which I'll take) or surgery to pare down the
troubling turbinates
(which I'll table for after this recuperation). Thank you,
doctor!
With the savings, I splurged on a few frivolous cosmetic
enhancements: A
dermatologist filled my naso-labial folds with Restylane,
paralyzed my
corrugators (the muscles between my eyebrows) with Botox
(combined cost:
$673), and eradicated the broken veins on my face ($44). I
spent another
$1,289 for a week's recuperation at a five-star resort that
the hospital
books for Western patients. Total price tag, with airfare
and a stop in
Frankfurt: about $9,000.
Few Americans use India's exploding, and rapidly improving,
private health
care system. But 150,000 foreigners went to India last year
for health-care
services ranging from chemotherapy and organ transplants to
cardiac bypass
and cosmetic surgery. (The population, interestingly,
including Arabs
barred from seeking medical care in the U.S. due to post
9/11 visa
restrictions and Muslim women barred from obtaining
abortions in their
homelands.) A two-year study concluded in April 2004 by the
Confederation of
Indian Industry showed that "medical tourism" in India was
growing at a rate
of 15 percent a year and had the potential to constitute as
much as 5
percent of India's total health-care delivery.
It's no secret how Apollo delivers so much for so little.
"Our wages are
one-fifth or one-sixth of what you pay in the U.S.," says
Prathap C. Reddy,
a cardiologist, who founded Apollo in 1983 and has turned it
into a chain of
35 hospitals with 6,800 beds, nine nursing colleges, and
more than 120
pharmacies.
(Some wages are lower than that: My staff nurses, who
sometimes worked as
many as 72 hours in a week, told me they made $4,000 a year.
The tips I
attempted to slip them were returned with scoldings.) Quite
simply, Indian
employees work much harder for much less than any American
worker.
I found myself wondering frequently how they found any time
at all to spend
with the families they cherished so much. Reddy has also
built multiple
efficiencies into his hospitals so that physicians are freed
up to spend
their time on patients, not paperwork. And technology --
just like people --
works at maximum capacity, resulting in economies of scale.
"We have three or four times more utilization of equipment,"
he says. "If
you do 15 CT scans in the U.S., I'll do 60 CTs here."
Virtually everything is cheaper in India, the ultimate
alternate economic
universe. Bose's malpractice insurance cost 8,000 rupees
(about $180) a
year.
Indian physicians, many of whom seemed to have a medical
ethos long lost in
the United States, often struck me as being more sensitive
and
philosophically simpatico to my own beliefs than many
medicos I'd
encountered at home.
As both a medical writer and a patient, I'd begun doubting
the supremacy of
American medicine long before going to India. Six years ago,
and after a
lifetime of worsening hip pain due to a genetic defect
called protrusio
acetabuli and early-onset arthritis, I was told I needed a
pair of total hip
replacements, or THRs.
While THRs are wonderful surgical solutions for elderly,
inactive people,
they wear out quickly in the young and intensely physically
active,
resulting in difficult revision surgeries and the
curtailment of many
cherished physical activities.
After almost two years of research and interviewing veterans
of various hip
procedures, I became convinced that my best option for
continued salsa
dancing, running, and climbing was the new-generation
Birmingham Hip
Resurfacing. I had insurance in 2001, when I traveled to
England to get one
for about $14,000, but my carrier refused to cover an
out-of-country
procedure. While the American propaganda mill spews endless
stories about
the horrors of socialized medicine, I was treated like the
most loved baby
ever born at the Royal Orthopaedic
(cq) Hospital in Birmingham. Not a single English person I
talked to in the
hospital wards would have traded their National Health
Service -- waiting
lists and all - for the capricious, laissez faire,
rigged-to-benefit-the-insurer system in the United States.
When it came time to get my second hip done, the falling
dollar meant my
surgery and a week's recuperation in England had risen to
more than $25,000.
There were FDA trials of knock-off devices going on in the
U.S., but even if
I had insurance (which I no longer did), it would not cover
resurfacing,
because FDA trials are considered "experimental," and
virtually all
insurance carriers refuse to cover prosthetic devices that
are not FDA
approved -- or non-emergency procedures performed abroad.
The cost for these
less established devices could run as much as $40,000 here.
I believed the
BHR had the best and most established track record of the
resurfacing
devices, and since I was delighted with my first one, I
didn't want to risk
anything else. Bose, who had trained with the BHR's
inventors in England and
installed more than 300 BHRs with only one failure, won me
over with his
thorough, detailed responses to dozens of niggling questions
that I deluged
him with via e-mail.
To a Westerner, many of the practices and traditions in an
Indian hospital
seem unfamiliar and sometimes downright loopy, but I found
it helpful to
intone my all-purpose traveling mantra: "Just because it's
different doesn't
mean it's bad."
After being delivered to my room from recovery, I woke up to
a breathless
interrogatory by a young woman clasping my hand. "I love
Jesus!" she
murmured fervently. " Do you love Jesus?!"
I thought I'd died and gone to Texas.
The Bible-toting evangelist turned out to be my private
nurse. Most nurses
working in Chennai, which is in the Indian state of Tamil
Nadu, are
Christians from the state of Kerala. They rival any hand
clapper in the U.S.
Bible Belt for religious piety. At one point I woke up to
find my television
turned to the God Channel, a televangelism network that airs
the Billy
Graham Crusade and The 700 Club. And I thought by going to
India I'd learn a
little about Hinduism.
My dream of a tranquil recuperation in a distant Southeast
Asian hospital,
far removed from friends, family, and employers, turned out
to be a joke
with a surprising punch line. As only the second American
not of Indian
descent to travel to this branch of Apollo, I was nothing
less than the
hospital's resident celebrity, a cross between Liz Taylor
and a touring
albino panda bear.
Endless deferential delegations of managers, from
housekeeping to food
service, tromped past my "Do Not Disturb" sign to query if I
was hungry, if
I'd enjoyed my meal, if my waste baskets were empty enough,
if I wanted my
Internet connection brought to life or my bed raised.
It wasn't just my origin that made me an object of
attention. Because I'd
arrived without family, the staff moved en masse to act in
loco parentis.
Apollo's director of medical services, N. Sathyabhama, MD,
explained that
because Indian custom dictates that relatives join a sick
person to assuage
loneliness and make her feel loved, people felt sorry for
me. No one could
grasp the concept of a patient actually wanting to be left
alone. The Indian
tradition of seeing each individual as a part of a family is
reflected even
in interior design:
Every room on my floor contained an extra bed for the "dear
one" patients
are expected to bring.
Sathyabhama also unraveled the mystery as to why I
distressed Dr. Bose so
much when, during a pre-op consultation, I told him that if
he accidentally
slipped and slashed my sciatic nerve, he should just unplug
all the
anesthesia machines and let me die rather than to allow me
to wake up with a
useless leg. I was just trying to articulate my preferences
in the event of
a worst-case scenario, but I'd clearly addlepated my doctor.
"Quiet! Stop
saying that!" he exclaimed.
"Poor Dr. Bose!" Sathyabhama exhorted when I recounted my
perplexing
conversation with Bose. "We Indians are very superstitious,"
Sathyabhama
explained.
"We don't talk about bad things. We think there are angels
around who hear
you and then think you want bad things to happen." She also
pointed out,
quite reasonably, that superstitions can have scientific
roots: Negative
thoughts can suppress the immune system and inhibit healing.
While health care practitioners in India are uniformly in
love with
high-tech gadgets, simple devices like long-handled
shoehorns and elevated
toilet seats for hip patients are not seen as necessary in a
culture where
relatives vie to perform every chore possible for an ailing
patient.
Economics are a factor: In a country where labor is usually
cheaper than
materials, it costs less to have nurses bathe and help
patients to the loo
than to provide wall-mounted shower heads or toilet seat
risers.
It was hard to be miffed over such inconveniences, though,
because the
overall eagerness by all to please was so endearing. When I
lamented over
the absence of the toilet seat riser, someone was dispatched
to mutilate a
red plastic lawn chair into a "potty chair" by carving a
hole into the seat
and dropping a black bucket into the new void. This hybrid
creation was
presented with great pride in a public hallway in front of a
busy elevator.
I didn't have the heart to explain that the chair was lower
than the toilet
seat, so I just bowed and said "nanri," the Tamil word for
"thank you."
The unexpected eruptions of humor were one of the things I
liked best about
Apollo. The day after the drain in my leg was removed, I
lamented to my
physical therapist, Syed (cq) John, that my leg felt so
swollen I thought it
might ex plode.
John regarded the bloated limb thoughtfully. "Maybe Osama's
in there," he
deadpanned.
I've always thought it advisable for white folks to take a
turn being the
minority, so I was not perturbed when other patients stared
at me. ("We
don't get a lot of whiteish people here," an administrator
explained
apologetically.) What unhinged me more was India's puzzling
and pervasive
color consciousness.
Newspapers are filled with ads for skin-bleaching clinics.
Solicitations for
prospective sons and daughters-in-law routinely stipulate
that applicants be
"fair." When I asked a (dark skinned) nurse about this, she
insisted that it
was simply a fact that lighter skinned people were more
attractive.
"But that's not true," I protested. "A dark-skinned woman
might be very
beautiful, but a light skinned woman could be very ugly."
She gave me a perplexed look and then shook her head
determinedly. "No," she
said simply.
Dr. G. Ravichandran, a dermatologist who zapped my facial
veins,
acknowledged with a "waddyagonnado" shrug that he obliges
the
about-to-be-brides who beseech him to lighten their skin.
I was saddened to hear a woman indict herself so
unquestioningly and
perturbed to see that such antediluvian beliefs still held
sway in a
society, that, in so many other ways, struck me as sweet and
progressive.
Then, I was struck with a "patient heal thyself" epiphany:
Who was a glutton
for cut-rate Botox?
Who loathed her own wrinkles? (Umm, that would be me.) Women
everywhere
allow themselves to be oppressed by their cultures in
different ways, and
judge themselves more severely than any outside critic, I
realized. Perhaps
it is up to each of us to challenge the perverted judgments
our communities
level upon us by first proudly accepting ourselves.
I was not a pioneer in discovering India's health-care fire
sale. On my
flight back to Frankfurt, I sat next to a "futures
researcher" for Nokia in
Dusseldorf who whipped off his baseball cap to display the
$500 hair
transplant he had obtained at the Apollo Hospital in
Hyderbad. At
Fisherman's Cove, the resort where I was sent to recuperate,
an American NGO
worker crowed that one of his colleagues had a successful
heart bypass at an
Apollo hospital for $5,000.
"What would that cost in the States?" he asked rhetorically,
"$100,000?"
My most illuminating encounter was in the lobby of the
resort, where I met a
radiant pediatric nurse and the wife of an American CEO. She
had outsourced
her children.
After spending $10,000 on U.S. infertility treatments, only
to have a Texas
doctor pronounce that she'd never get pregnant without donor
eggs, Rebekah
Cessna went to a hospital in Delhi and plunked down the
equivalent of $1,000
on one final attempt to get pregnant. By American standards,
Cessna
recalled, "the hospital where I had the IVF done was very,
very primitive.
But my doctor gave me her cell phone number and I always saw
her
personally." After a single IVF procedure, Cessna delivered
twins in 2001.
Cessna, who has rave reviews for her own treatment in India,
is never the
less troubled that so many Indians don't receive even basic
health care like
emergency treatment or vaccinations. "People here die!" she
says. "The
mother of one of my ayahs (nannies) had a heart attack, and
the hospital
wouldn't even give her oxygen until they got the money up
front. I'm always
giving people money to go see the doctor because they just
can't afford it."
I share her unease and First World guilt. As grateful as I
am for my
incredible hip, and to see "VIP" stamped in green on every
page of my chart,
I felt ambivalent about getting such high quality care in a
country where
few of the people who need medical care receive any, and
poor people place
newspaper advertisements appealing for funds to finance
life-saving heart
surgeries.
Is it really ethical for comparatively well-off Westerners
to obtain their
medical care in a country that spends less than 1 percent of
its gross
national product on health care (the U.S. spends 15
percent), and still
struggles to eradicate dengue fever, tuberculosis, polio,
and leprosy?
The Confederation of Indian Industry argues that it is.
Serving foreigners,
its members believe, fuels a desperately needed expansion of
health care,
improving quality, raising treatment standards, and
promoting price
transparency.
V. Shivaram Bharathwaj, MD, the consultant plastic surgeon
who nicked off my
fibroma, assured me that treating Westerners was unlikely to
obstruct the
delivery of care to Indians: "These things have their own
checks and
balances," he says. "It wouldn't be smart to be dependent on
foreign
patients. There could be a SARS scare, or a jihad scare,"
leaving empty any
hospital that relies exclusively on foreigners.
Reddy, the cardiologist who runs Apollo and who is known
throughout the
country as the father of Indian health care, contends that
foreigners offer
the best hope of funding an expansion of health care in
India; he intends to
fill 30 percent of his hospital beds with them. When I asked
him about the
possibility of foreigners occupying hospital beds that his
own countrymen
need much more urgently, he laughed and acknowledged, "Your
question is
asked by Indian experts, too." Then he added, "My conscience
is very clear."
He notes that one of Apollo's major missions is to give
rural Indians
desperately needed access to health care. Towards this end,
Reddy is
establishing tele-medicine satellite clinics so that
specialists from afar
can diagnose and work with doctors in remote areas to treat
patients with
complicated problems.
Apollo also has a foundation to subsidize medical care for
the poor. It made
me queasy to realize that private sector pioneers such as
Reddy are India's
best hope for improved health care. On the other hand, it's
hardly fair to
fault the man who irrigates the desert for not bringing
water to every grain
of sand.
Reddy likes to tell the story of the patient who inspired
him to start his
hospital chain. In 1979 a young man he was treating needed a
coronary
bypass, but Reddy didn't have the equipment to perform one
and urged the man
to fly to the U.S. for the operation. But the patient
couldn't afford to
come here, and he died. Reddy, who had practiced in the U.S.
before
returning to India, resolved right then to give his country
health care as
good as any found abroad.
Twenty-six years later, India's burgeoning middle class is
enjoying the
fruit of Reddy's vision. Strangely, his crusade to provide
care for
underserved Indians has resulted in an opportunity for
Americans who,
increasingly, are left uninsured or are unable to afford the
extortionate
costs of drugs and health care in their own country, which
once served as a
shining model for the world.
If you're thinking of going to India for elective surgery, here are
some
issues to consider:
* Plan ahead. You have to get a typhoid vaccination and a
prescription for
anti-malaria medication that should be started one week before going
abroad.
Some people also elect to get hepatitis vaccinations to be extra
safe.
* Buy drugs. Thanks to enlightened price regulation, drugs in India
are
phenomenally inexpensive - often just five percent of the prices
charged in
the U.S. - and you can obtain common medications such as antibiotics
without
prescriptions. The copycat versions of drugs sold there are
generally every
bit as good as the versions available Stateside. You do have to be
pharmaceutically savvy, though, and carefully monitor what you're
given
because "lost in translation" episodes may happen due to simple
misunderstandings and brand names that differ from country to
country. Make
sure to check the names of all the medications you receive, and if
you don't
recognize a drug name, look it up in a Physician's Desk Reference.
Also,
pills and tablets are dispensed in uninformative blister packs with
minimal
labeling and no circulars listing potential side effects,
contraindications,
or interaction possibilities. My doctor misunderstood my request for
Imitrex, a brand name migraine drug, and I was instead handed
methotrexate,
a drug for rheumatoid arthritis that, in larger doses, is used to
treat
cancer and to expel ectopic pregnancies. I caught the error, but the
episode
reminded me that it's imperative to double-check every drug you're
dispensed
whether you're in Tamil Nadu or Terre Haute.
* Research! Other patients are the best sources of information when
preparing for an operation abroad. They can help you select a good
doctor,
prepare for your trip, and tell you what to expect. In the Internet
age,
they're also easy to find. If you're contemplating a procedure
abroad, join
an on-line support group. (You can usually find one by Googling your
condition or the procedure you plan to have with the words "support
group."
My hip resource was
<http://health.groups.yahoo.com/group/surfacehippy>.) Ask members of
the group
what they wish they'd known before going and call them to get the
full
story.
Thanks to a fellow member of "surfacehippy" who was resurfaced at
Apollo
before me, I knew ahead of time that the hospital wouldn't provide a
sock
gutter or a grabber, both of which I would need to dress in my first
post-op
weeks, so I brought them along.
* Vet your surgeon's credentials. This is hard enough to do in the
United
States, where bogus "board" certifications abound and laws err on
the side
of protecting physicians' reputations. In India, physician training
can be
highly variable, warns Vijay C. Bose, MD, my orthopedic surgeon. But
the
minimum credentials that any surgeon should have are "master of
surgery" and
"doctor of medicine" -- degrees that indicate government approval.
An
"FRCS" (Fellow of the Royal College of Surgeons) after a name is
even more
reassuring because it indicates that a physican trained in Britain
and
passed rigorous board exams there. Shivaram Bharathwaj, MD, a
consultant
plastic and reconstructive surgeon at Apollo, warns bottom-fishing
patients
against hiring medical go-betweens and resorting to "one-off
clinics" where
a doctor is "running a one man show."
Doctors affiliated with large private hospitals with good outcomes
and
reputations are a much safer bet, even if they cost more.
* Know your risks. While Apollo is planning to offer "complication
insurance" (at about 5 percent of a procedure's overall cost), at
this point
surgery in India is pretty much caveat emptor. Should your surgery
result in
a misadventure and you decide to sue, your case will be tried in an
Indian
court.
* Go with your gut. I'd been following my surgeon's career through
website
reports for years and knew that he had been trained by the inventor
of the
BHR.
I was also reassured to know that he had implanted more than 300
BHRs with
only one failure and was an international expert in avascular
necrosis. What
persuaded me to fly over, though, was how patiently, thoroughly, and
humbly
he responded to each of the dozens of questions I addressed to him
by
e-mail.
* Talk to your surgeon about what to expect in the recovery room.
The
recovery room experience can vary amazingly, but doctors never tell
you what
to expect and patients never ask. I was braced to suffer after my
first
surgery in England, but it turned out to be a snap. (Forty-five
minutes on
the table, and no pain other than an inflamed vein in my hand, which
an
anesthesiologist
remedied.) I assumed I'd wake up this time in another cozy swaddling
of
warmed blankets and anesthesia-enhanced bliss. Surprise! Because the
leg
lengthening procedure stretched this op to four hours and prevented
my
doctor from flooding the area with local anesthetic before closing
the
incision, I woke up in a fireball of pain. My hip hurt, my throat
was
painfully parched and I started screaming because I couldn't see and
my eyes
felt like they were full of sand.
(They had dried out.) I'm still mortified by having shrieked bloody
murder
in the recovery room, surrounded by dignified Indian patients who
didn't so
much as moan. I like to think that if I'd been steeled to expect
some
post-op discomfort and ordered up throat lozenges and eye drops in
advance,
I might not have provided the international community yet more
evidence that
Americans are really a bunch of sniveling, egotistic sissies.
* Consider finding your own pre- and post-op lodging. Private
hospitals
imagine Western patients to be so finicky and scared of "real"
India, they
book you into the most expensive and luxurious hotels in the
country. By
Western standards, the prices are cheap for what you get (I paid
about $136
a night plus a
12 percent luxury tax to stay in Fisherman's Cove, an edenic,
Westernized,
five-star Taj resort), but once incidentals and meals are added in,
the
costs can add up quickly. You can find charming, cheap, and sanitary
post-op
lodgings for less than $50 a night, but you'll have to scrounge them
up
yourself well in advance, as the best bargains fill up quickly.
* Brace yourself for the return flight . . . which, in my case, was
worse
than the operation. Because patients having major joint surgery are
at
especially high risk for deep vein thrombosis during long flights,
Bose
recommends delaying return for as long as possible -- two weeks
minimum--
wearing anti-embolism stockings, and planning a layover in Europe or
Singapore to break up the time you spend in air prison. If you've
amassed
frequent-flyer miles, it's definitely worth it to use them on an
upgrade.
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