Dr. Anand Bharathan

Sr i Ramakr i shna Hospital,

Coimbatore

Consultant Surgeon, HPB Surgery

India is a country of 130 crore people. Due to individual, soc ial and pol iti cal wi l l, respectable improvement has been made in literacy rate and health care indices of our cou n tr y a f t e r we g a i n e d independence from foreign rulers. However, to this date, a significant majority of our population lives below the poverty line. Access to qualitative, basic and advanced health care remains unequal both in rural and urban India. Even in urban India, access to good quality health care remains beyond the capacity of the vast majority of Indians. Multiple factors are responsible for the inequality in access to health care. These include rapidly increasing population, poor per capita health care spending by government, hesitation of  specialist doctors to serve in rural/remote areas, absence of a well- oiled, tiered public health care system in urban areas, failing to maintain world class standards in many public sector hospitals and consequent mushrooming of corporate health care providers. Corporate health care providers, in many instances, provide high quality health care that our public hospitals struggle to consistently provide. Despite their quality, corporate medical services result in huge “out of pocket” payments and result in “treatment induced poverty” as most people either borrow money or sell their meagre property to fund their health care. Most of our population is not covered by health care insurance that is optimal and adequate despite exhibition of political will to do so.

Liver transplantation in our country exemplifies all of the problems of access to health care that I have outlined earlier. Almost all except two liver transplantation programmes in our country are run by corporate hospitals. As I would detail later, getting a liver transplant operation done in any of these hospitals costs a fortune. Among the few public hospitals in the country that routinely perform liver transplantation, only one provides this service “absolutely free of cost.” The poor and lower middle class has literally no access to liver transplantation. With this background, it is amply clear that access to liver transplantation is negligible for the majority our country’s population.

Liver transplantation in corporate hospitals of India costs around INR 2.5 million (USD 35,200). Almost all of the luminaries of liver transplantation in our country are working in corporate hospitals and a significant majority of them are expatriates, who have returned to India to establish highly successful liver transplant programmes. Most of them argue that the cost of liver transplantation in our country is much more economical compared to what it is in the West (where it is 5-6 times more expensive) and that we should really be happy that our people have access to high quality liver transplantation for this cost. But, in a country where the per capita income is a mere USD 1670 and distribution of even this meagre income is very unequal, how can an average Indian afford liver transplantation in a corporate hospital?(1) The most common fate of an economically underprivileged Indian (including children), who has liver failure, is to die without ever getting close to liver transplantation. The best way to perform liver transplantation is doing “deceased donor liver transplantation” (DDLT) as the overall health care impact of this form of liver transplantation is better than “living donor liver transplantation” (LDLT). This is because LDLT involves an operation in a healthy individual, the donor, to remove a part of his/her liver through a major operation. The donor takes time to recover and loses a significant amount of time to get back to normal life. Besides, LDLT is a technically difficult operation. Therefore, the success rate and long-term complications of LDLT remain undeniably poorer than that of DDLT. In view of these reasons, LDLT is almost exclusively performed only in corporate hospitals of India, which are able to aggregate trained manpower resources required for the performance of this complex operation. The more doable DDLT operation remains a less commonly performed operation due to lack of awareness about organ donation and the long-term impact that it could have on the health care economics of the field of transplantation in this country. Unfortunately, this has led to some in corporate medical practice to come to an unfortunate conclusion that LDLT is the way forward in countries like ours!(2)

The intention of this article is to tell readers as to why altruistic deceased organ donation is more important than ever in these times of great inequality between poor and the affordable in access to organ transplantation, despite the fact that the most common deceased organ donor in this country comes from an economically underprivileged section. If we understand this well, it could change the health care economics of the field of organ transplantation in our country in the long term. I also aim to give my views on how this could be achieved.

Promoting organ donation, therefore, most often involves asking families of brain dead (read, most often, Below Poverty Line!) individuals to consider an act of greatest altruism at the moment of their greatest grief. Very often, this is to benefit an economically privileged fellow citizen waiting for transplantation in a corporate hospital, one who is able to afford this expensive care.

Relative technical ease of performance of DDLT could result in a higher number of surgeons and teams getting an opportunity to acquire skills in performance of this operation, if only deceased organ donation increases. This could invariably result in higher number of hospitals setting up teams for performance of DDLTs with successful outcomes. When successful outcome after a widely available procedure becomes commonplace, the corporate health sector is likely to lose the exclusivity that it has on the procedure. Requirement for LDLT will come down or even potentially, disappear. The latter situation is exemplified by very low LDLT rates in many Western countries, as DDLT   is widely available there. All this could result in liver transplantation becoming available at a cost that most of the population could afford. Thus, if we need to bring in some equity in access to liver transplantation, promotion of organ donation and thereby, DDLT is the urgent need of the hour. This is precisely the reason why we must put all our efforts and resources into promotion of organ donation, right now!

Even when DDLT becomes widely available, it may not be possible to offer it to all those who need it. Potential reasons could be inability to afford even a small amount of money for the procedure, poor sanitary conditions at their homes that preclude safe post-transplant care and poor social support at homes of the lowest rung of economically underprivileged people. Another round of thought process and activism will be required at that point of time to bring more inclusivism in access to transplantation. The ideal long-term solution for this would be elimination of poverty completely. That is a dream that could take much longer to achieve. The most cost-effective solution for the problem till such time, for diseases of liver could be prevention of liver diseases.

The most common indications for liver transplantation in our country are alcohol related liver failure, non-alcoholic fatty liver disease related liver failure and viral infections like hepatitis B, hepatitis C, hepatitis A and hepatitis E. Most of these causes of liver failure are preventable. The cost of preventing liver transplantation by educational outreach would be much lower than performance and provision of long-term care after liver transplantation. Thus, it is imperative that while we promote organ donation among our people, we are duty bound to simultaneously educate people on the preventive aspect of liver diseases.While governments and private entities will continue to produce, market and sell alcohol always, it is up to people to consume it or reject it. Almost every second transplant that I have been involved in was to treat liver failure due to alcohol abuse.

Most of my peers who perform liver transplantation have shared similar experiences. While promoting organ donation among the masses, we need to emphasise that alcohol is a great health hazard. We need to tell people that alcohol could lead not only to liver failure, but cause major health hazards like pancreatic disorders, cancers in multiple organs and loss of productive workforce. Even if one among 10000 people whom we take this information to listens to our repetitive advice on this, we would prevent one liver transplantation resulting in saving a huge, long-term health care burden.

Fatty liver disease is a lifestyle disorder caused by excessive consumption of carbohydrate or fat-rich food and failure to perform adequate physical activity. We need to make the general public aware that a calorie conscious diet, avoidance of sugar-rich soft drinks and daily exercise could prevent not just liver disease, but also prevent various other non-communicable diseases like cardiovascular ailments. Hepatitis B could be prevented by routine vaccination using a highly effective, economical and widely available vaccine. Hepatitis C could be prevented by careful attention to prevent blood borne infection. Hepatitis A and E could be prevented by widespread access to safe water and food.

Thus, while we promote organ donation with a clear vision and communication of how it could change the landscape of organ transplantation in future, it is imperative for us to strive hard to simultaneously provide information to people on preventive aspects of organ failure. Such a plan would have a far-reaching positive impact on not just provision of donors for organ transplantation, but would go a long way in prevention of organ failure. Most importantly, such a plan is likely to restore public trust and confidence in the process of organ donation and the field of organ transplantation in our country. Doctors in both public and private sector hospitals must be participants in this proposed attempt to restore the confidence of the common man of this country in the integrity of the field of organ transplantation.