BHR Dr. Bose in India 2004

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 explode.  

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.

Additional Information

 

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.