An introduction to Ratna Magotra’s Whispers of the Heart: Not Just a Surgeon (Konark Publishers) and a conversation with the doctor who took cardiac care to the underprivileged.
“I slept and dreamt that life was joy. I awoke and saw that life was service. I acted and behold, service was joy?”— Tagore, Whispers of the Heart: Not Just a Surgeon by Ratna Magotra
“There are at least five estimates of the number of poor people in India, which put the number of poor in India between 34 million (equivalent to the population to Kerala) to 373 million (more than four times the population of West Bengal). This puts the number of the poor between 2.5% of the population to 29.5%, based on different estimates between 2014 and 2022.”
— Scroll India, 5/5/2023, Nushaiba Iqbal, IndiaSpend.com
How are the healthcare needs of the poverty stricken met in a country with a vast number who are unable to foot their daily food, housing, and potable water needs? This has been a question that confronts every doctor in cities where labourers who build housing for the middle class are themselves homeless just like the street side immigrants who beg. Even dwellers of shanties that spring up around colonies of the well-to-do to provide informal labour to the affluent are hardly any better off. Few in the medical profession move towards finding solutions to bridge this gap.
Dr Ratna Magotra, who moved from Jammu to find a career in healthcare in Mumbai, is one such person. Recently, she wrote an autobiography which has consolidated the work being done by cardiologists to bridge this gap. In her book, Whispers of the Heart: Not Just a Surgeon, while identifying this divide, she writes: “Poverty, inequality, deficient primary healthcare, unequal access, and the escalating commercialisation of medical care were causing an angst that I found difficult to make peace with. As medical practitioners, our expertise lies in providing treatment, but we often overlook the broader social factors underlying ill health. It might escape the attention of a surgeon performing intricate heart surgery that a child who survived a complex heart surgery could succumb to diarrhoea due to the lack of access to clean drinking water. Issues like malnutrition, skin infections, superstitious beliefs, and poverty may be the harsh realities in the patient’s actual living conditions beyond the confines of sanitised medical environment. /Medical training, regrettably, seldom includes the connection between poverty and disease.”
The land reforms laws that followed post-Partition[1] led to her family losing their wealth. But Magotra bears no ill-will or scars that have crippled her ability to contribute to a world that needs to heal — of taking healthcare to those who can’t afford it. She starts her biography with vignettes from her childhood: “I recall that the agricultural land we owned in our village in Jammu was considered very fertile with the best Basmati rice grown there. Though I was very young, I have faint memories of the house amidst lush paddy fields and a small stream that we had to cross to enter the village. It was very close to the international border between India and Pakistan. The way my mother was respected reflected the high esteem that villagers had for my father. Though their tenant status had changed to that of being landowners, the villagers visited the house as they did before and received generous gifts from her. /They would indulge us children with home-made sweets made of peanuts, jaggery and spices. Rolling in heaps of post-harvest grains piled up in open fields was great fun.”
She lost all that and her father. But with supportive family and friends, drawn to healthcare, she became a doctor in times when women doctors were rare. If they at all specialised, it was mainly in gynaecology. She chose cardiac surgery trained in UK and US. She made friends where she went and with a singular dedication, found solutions to access the underprivileged. She elaborates: “The quantum leap in India’s healthcare sector occurred during the 1990s following the economic reforms and the liberalisation of the economy. The end of the licence raj system facilitated the imports of advanced technology and medical equipment. Specialists, who had long settled abroad, began contemplating a return to India.”
While she attended an International Course in Cardiac Surgery at Sicily to update her skills, she tells us: “During our interactions, some German surgeons raised questions about the rationale behind a developing country like India engaging in an expensive speciality like cardiac surgery. I realised how biased opinions can be formed and spread, though rooted in ignorance. /By this point, however, I had grown accustomed to explaining the paradox — why it was essential for India to advance in specialised care alongside its priorities in basic healthcare and poverty alleviation.”
She cites multiple instances of cases that she dealt with from the needy rural population, for who to pay prohibitive costs would mean an end to their family’s meals. Magotra writes, “I had seen numerous poor heart patients who suffered not only from the ailment itself but also from financial burden of the treatment. The medical expenses incurred for a single family member affected the well-being of entire household, depleting their limited resources and savings. Unfortunately, medical education does not include health economics as a subject. As a result, doctors, especially specialists, trained in a reductionist approach to diseases tend to move away from a holistic perspective. They readily embrace new technological advances, often neglecting proven and cost-effective treatment options. This, in turn, drives up healthcare costs and makes it unaffordable for the common man.”
Living through a series of historical upheavals, she brings to light some interesting observations. She came in contact with Jinnah’s personal physician while looking for a placement in Mumbai. There she mentions that many wondered if the Partition of India could have been averted if this doctor had shared the information that Jinnah had limited life expectancy as he had advanced tuberculosis. She has lived through floods in Mumbai and riots and wondered: “I was staring at the blood on my clothes, which had come from multiple patients. In that quiet moment, I couldn’t help but wonder if there was a ‘test’ to distinguish between a Hindu blood and a Muslim blood.” She joined the anti-corruption movement started by Anna Hazare and fasted! She has travelled and watched and collected her stories and she jotted these down during the pandemic to share her world and her concerns with all of us. In the process, recording changes in health care systems over the years… the historic passing of an era that documents the undocumented people’s needs.
An award-winning doctor for the efforts she has made to connect with people across all borders and use her experience, she talks to us in this interview about her journey and beliefs.
What made you write this book? Who were the readers you wanted to reach out to?
I had asked myself the same questions before I started and even while I was writing: Why and for whom?
Some younger friends and family members would find the anecdotes and stories, I would relate to them from time to time, interesting. They would often prod me to write about these. People, situations, my travels to places — not the usual popular tourist destinations, invoked further curiosity in them to know more about my life. As such I like to write my thoughts (usually for myself) and have been contributing small articles to newspapers, magazines, and Bhavan’s Journal for their special Issues. The pandemic provided me an opportunity to contemplate further when I seriously considered about writing an autobiographical narrative.
As I progressed with my account, I envisaged a wider readership outside the medical community as multiple facets emerged about places, people and events of varying interests.
What were the hurdles you faced while training as a doctor — in terms of gender and attitudes of others?
Fortunately, I can’t recall any specific hurdle or adverse experience because of my being a woman. Studying for MBBS degree at Lady Hardinge Medical College (LHMC), made it a normal affair as LHMC was an all-women medical college.
The struggle that I faced in getting PG admission in Bombay also had nothing to do with gender. The problem was being an outsider in Bombay when number of seats were limited. Students from local medical colleges and rest of Maharashtra had first preference for selection to PG courses. Anyone in my place would have had to go through a similar grind as I did.
Once PG admission was secured, it was smooth sailing through training and working alongside male colleagues! I asked for no concessions being a woman and worked as hard as they did or may be little more. We had a very close and harmonious working relationship with healthy mutual respect leading to lasting friendships.
What made you choose cardiac surgery over other areas of specialisation?
The decision to become a doctor and a surgeon was firmed very early in life. Interest in Cardiac surgery was acquired much later when I started working with Dr Dastur in Bombay. Seeing and touching a beating heart was fascinating and at the same time very challenging at that time. I was tempted to take it up for further specialisation. And yes, it was a very glamorous specialty at that time with names like Denton Cooley[2] and Christiaan Barnard [3]making waves in mainstream conversations!
Cardiac surgery was perceived by some as the forte of the rich, but you have shown how many villagers also had the need for the same specialised care. So, what was it that made you realise that? What could be seen as the incident that made you move towards closing social gaps in your horizon?
Heart disease affects the rich as also the poor. In fact, in earlier times when lifestyle diseases were not as common, it was the poor who suffered more from many afflictions including heart disease. Rheumatic heart disease was the bane of the underprivileged, living in overcrowded spaces with repeated streptococcal throat infections that eventually ravaged their heart valves. Congenital heart disease was common though not diagnosed as often. While the rich and affluent could afford to travel abroad to get treatment, in turn costing precious foreign exchange to the nation, others had to make do with whatever was available. Indian surgeons stretched their resources, skills and imagination to fill the gaps in the infrastructure.
Working in teaching hospitals, I saw the suffering and helplessness of the poor from very close. Inadequacies in healthcare stared at us every day. Moreover, those days cardiac surgery was being performed only in 4-5 teaching hospitals in the country.
I tried looking beyond the patient, connecting their illness with the social and economic environment they came from. Their personal courage, resilience and faith in overcoming difficult moments of life stirred something inside me. One such incidence involved a patient, Ahir Rao, from interiors of Maharashtra. His surgery at KEM and my subsequent visit to his home opens the chapter on ‘Reaching the Unreached’ in my book.
Ironically flip side of development and changing economic status, is that lifestyle diseases like hypertension, diabetes and heart disease are affecting less affluent even more. Lack of awareness about diet, and rapidly adopting urban fads have changed the rural-urban spectrum of heart disease.
The prejudices and biases of the developed countries influenced many in the country also to question a developing country like India from investing in super-specialty like cardiac surgery instead of focussing on providing basic amenities to the people.
It was amusing to see the BBC presenters asking the chronic questions as recently as the landing of Chandrayaan on moon in August 2023 — whether India should have space missions? Persistence of same mind set exposed their ignorance about the benefits the technology and the science bring to common man as also reluctance to accept the progress India has made!
How did your travels to other countries impact your own work and perspectives?
Traveling is a great education to broaden one’s horizon. My travels in India and to different countries contributed towards my personal growth by helping me connect to the geography, nature as also the people belonging to different cultures and sensibilities. Different foods, attires or attitudes but with one common underlying bond of humanity with similar aspirations.
Professionally, going to advanced centres exposed me to a work culture that was very different from ‘chalta hai’ [4] attitude back home. Staying ahead with the best research, better working conditions, new technology were just the stimulants I needed in doing better for our patients.
There were many people you have mentioned who impacted you and your work. Who would you see as the persons/organisations who most inspired and led you to realise your goals?
I owe so much to so many people, whom I met at different stages of my life and who influenced my thinking, values and my work. It is difficult to pick one or two, however, if asked to narrow down to three or four most important individuals, these would be my mother and Prof Rameshwar in early years, and Dr K. N Dastur in my professional choice and career. However, biggest influence in my later life has been my Guru, Swami Ranganathananda — who imparted the wisdom of practical vedanta giving ultimate message of oneness and freedom of thought and action for universal good as propagated by Swami Vivekananda.
Why did you join Anna Hazare and his organisation? How did it impact you? What were your conclusions about such trysts?
I had heard of Anna Hazare as an anti-corruption crusader and had met him once at his village while accompanying Dr Antia. It was very admirable the way he had motivated the village people to participate voluntarily in the economic and social development making Ralegaon Siddhi a model village. This simple rustic person could stand up to the high and mighty and often made news in local newspapers; the politicians took his protests seriously at least in Maharashtra. When India Against Corruption (IAC) came into existence in 2011, I didn’t think twice before joining the unique coming together of civil society to fight corruption in the highest corridors of power. I was personally convinced that corruption had eroded and marred the dream of India keeping the common people poor and backward even as the corrupt flourished. As an individual, one could not do much beyond complaining and paying a price for a principled life. It required the civil society to stand up collectively to oppose the corrupt who were (are) actually very powerful!
There was nothing personal to gain by joining the protest but only lend my voice to the common objective of checking, if not eradicating, the menace of corruption.
The experience, highs and lows of the movement form a chapter in my book. The movement becoming political and losing the momentum of a countrywide movement was a big disappointment.
What would be the best way of closing the divides in healthcare?
There has been some forward movement in healthcare at grass root levels in last two decades or so. These gains need to be streamlined as at present we have islands of excellence with vast areas of dismal healthcare — the imbalance needs correction.
Increased spending by the State for healthcare, forward looking national health policy keeping in mind the diverse needs of such a vast country, rural urban realities are the way forward. Investment in medical and nursing education, primary health care, paramedics, rational use of appropriate technologies — all these need to be considered in totality and not in isolation.
Lot of the healthcare work is bridged by NGOS as per your book. Do you think a governmental intervention is necessary to bring healthcare to all its citizens?
My narrative belongs to the eighties and nineties when NGOs were vital in taking basic medical services to remote places where none existed. These organisations did a herculean task and several continue to be a significant provider even as the governments, both at the Centre and State level, have initiated many schemes that include healthcare besides general rural development. I personally think that the NGOs too need to retune their earlier approach of being stand-alone providers seeking funding from government and foreign donors to remain relevant. NGOs, though a vital link between the governments and the communities, have traditionally taken adversarial position to the governments. While keeping their independence of work, maybe they should strive to avoid duplication of services; provide authentic data, and create awareness. These along with constructive criticism and cooperation would benefit the communities and the stakeholders alike. Health education, women empowerment, strengthening the delivery of healthcare integrated with holistic rural development are best done by NGOs working at ground level.
What reform from the government would most help bridge these gaps and can these reforms be made a reality?
The question has been partially answered as above. Increase in budgetary allocation and intent are the prime requirement with focus on nutrition, clean drinking water, sanitation (end of open defecation, provision of toilets, is a major reform) and clean cooking fuel impact public health at grassroots substantially, especially that of women and children. These alone should reduce the load of common diseases and prevent 70 to 80 percent of maladies in a community. This is similar to what Dr Antia used to advocate — “People’s health in People’s hands”. No medical specialists are required, and community health workers would be fully capable of taking care of routine illness. The gains would need to be evaluated periodically to see the impact by way of reduced infant mortality, maternal health, reduction in school dropouts and increase in rural household incomes. Use of technology is an important tool to connect the masses with healthcare centres for more advanced care.
More thought is necessary for specialist oriented medical care. I am aware that we have some very wise and thinking people at the top deciding on national medical policy that should actually map the number of specialised centres and the doctors in each specialty and super specialities (SS) required over say next 10 years. The number of training programmes should be tailored accordingly. It is saddening to know that so many seats for post-doctoral training continue to remain vacant. It is specially so in surgical SS like cardiovascular, pediatric, and neurosurgery that are seeing less demand with interventional treatment making roads in treatment.
The change in the attitudes of administration as also the medical community is important. The benefits should be harvested with honest appraisals for course correction where needed for better planning in consultations with doctors, civil society, and the NGOs working in the rural areas.
Another idea close to my heart has been to motivate or even incentivise the senior medical practitioners to serve the rural areas for 2-3 years prior to their retirement from active service. They would carry experience and wisdom to manage medical needs even with limited resources as compared to enforced bonds for fresh graduates who are short of practical experience, anxious about their future and that of the families. Seniors on the other hand have fulfilled their responsibilities and may be really looking forward to satisfaction of giving back to the society. Having secured their future and relatively in good health, can be very useful human resource for the governments and the communities. This should be entirely out of volition and not under any pressure from the authorities.
Now that you have retired, what are your future plans?
Life is unpredictable at my age. I would, however, wish to remain in reasonable health to be able to be a useful citizen. I have no firm plans and will go where the life takes me like I have done so far.
I am aware that the age would no longer allow me to continue with specialised and highly technical profession I am trained for. Modern communication has narrowed the distances and made it possible to stay connected. I should be satisfied if I can provide any meaningful inputs, retain the attitude of service and remain contended in my personal being.
[1]JAMMU AND KASHMIR AGRARIAN REFORMS ACT 1976
https://law.uok.edu.in/Files/5ce6c765-c013-446c-b6ac-b9de496f8751/Custom/local%20laws%20(4%20files%20merged).pdf. With the end of Dogra rule in 1947, a historical legislation called the Jammu and Kashmir Big Landed Estate Abolition Act was passed in 1950. The Act abolished the large, landed estates by fixing the ceiling area.
[2] American cardiothoracic surgeon (1920-2016)
[3] South African thoracic surgeon (1922-2001)
[4] Casual attitude that anything works
CLICK HERE TO READ AN EXCERPT FROM WHISPERS OF THE HEART
(The online interview has been conducted through emails and the review written by Mitali Chakravarty.)
PLEASE NOTE: ARTICLES CAN ONLY BE REPRODUCED IN OTHER SITES WITH DUE ACKNOWLEDGEMENT TO BORDERLESS JOURNAL.
Click here to access the Borderless anthology, Monalisa No Longer Smiles
Click here to access Monalisa No Longer Smiles on Kindle Amazon International
Borderless 