Donating lives with Heart transplantation

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Donating lives

Heart transplantation can hold out hope for a large number of patients in India but a smooth donor mechanism will need to be put in place and the costs involved will have to become affordable to more people before the numbers of such procedures can reach levels comparable to developed countries.

RASHEEDA BHAGAT

IN a special room in Apollo Hospitals in Chennai, 36-year-old A.S. Subramaniam, who received the gift of a 'new' heart a couple of weeks earlier, spoke about the operation that gave him a new lease of life. According to him, the operation went through like a dream, the bill amounting to around Rs. 3 lakhs has been taken care of, and he is accorded "royal" treatment.

Yet, even as he speaks about his good fortune, a dark shadow clouds his face. While on the one hand he is happy that his four-year-old heart problem has been solved, Subramaniam, an executive engineer with Neyveli Lignite Corporation (NLC), is worried as to how he will raise the enormous amount of money required to maintain the foreign organ in his body.

After he suffered a heart attack in June 1994, Subramaniam required regular medical help. He told Frontline: "I was told by my cardiologist that the only remedy for my terminal heart problem was a transplant." With a take-home salary of barely Rs. 7,000, Subramaniam, who has a wife and two children aged 11 and six years to support, had no hope of raising the Rs. 3 lakhs required for a transplant. However, when a donor organ became available and the Apollo Hospitals' cardiac surgery team volunteered to perform the surgical procedure free of cost and take care of the material as well as hospitalisation costs, it was like a dream come true.

However, Subramaniam now has to raise Rs. 2 lakhs, which is required over the next 12 months for various medical tests and for immuno suppressants required to prevent rejection of the organ. The monthly expenses on immuno suppressants, such as cyclosporin, range between Rs. 4,000 and Rs. 10,000. (The dosage will come down progressively.) Subramaniam has no assets other than is ancestral house in a small town in Tamil Nadu. "Even if this house is sold," he said, "my sister has to be given her share." He has no idea about how much NLC will contribute towards his medical treatment.


BY SPECIAL ARRANGEMENT
A heart transplant procedure in progress at Apollo Hospitals in Chennai.

GAJANAND GUPTA, 39, was the first patient on whom a heart transplant procedure was performed at Apollo Hospitals in Chennai. After living with a diseased heart for 10 years, during which period he had to close down his business, he received a 'new' heart on December 24, 1995. "When I was in the hospital, I was told that my lifespan could be as short as four days or as long as 40 days. So, when the heart of a 28-year-old accident victim became available, I told myself: 'I may die after four days. If the operation is not successful, I will die today. What difference will these four days make to my life?' So I agreed to the surgery."

Three years later, Gupta, who works as a ticketing agent for a domestic airline, is fit enough to meet the rigours of his job which requires him to do a lot of running around. "This is the best treatment in the world for myocardial patients," he said, "provided you can afford it."


BIJOY GHOSH
A.S. Subramaniam, who recently underwent a heart transplant surgery at Apollo Hospitals.

Although the Apollo Hospitals' cardiac surgery team has been very supportive and he is certain that the doctors themselves pay for the investigations, Gupta still needs to raise the money for cyclosporin month after month. "Until now I have managed to get by on help from the doctors, my friends and relatives. But frankly, if I had known that it was going to require so much of money to keep breathing, I wouldn't have gone in for the surgery. Unless you have the money, you end up being a beggar," he said ruefully.

In a developing country such as India, the operative words are "afford it". Although the most positive aspect of a heart transplant procedure is that it bestows a new lease of life on its beneficiaries, the prohibitive costs involved may prove to be a deterrent to many. Ironically though, most of the patients who have undergone a heart transplant are those who could not afford it and have had to depend on charity to pay for their immuno suppressants.

There are also people such as R.S. Sudarshan, a businessman who underwent a heart transplant at the Madras Medical Mission, who are able to bear the entire cost of the treatment. But people like him are few and far between.

THE high cost of surgery, medical investigations and the prolonged post-surgical medication is not the only factor that has kept the number of heart transplant procedures in India at an abysmal low. Donor hearts are also hard to come by.

Dr. M.R. Girinath, chief of the cardio vascular department at Apollo Hospitals, pointed out that even though the surgical aspect of a heart transplant is simple, the lack of awareness and the dearth of organ donors have led to a situation where the number of heart transplants performed in India is very low. Over the past four years only 25 heart transplants have been performed in the country. Dr. Girinath said: "The few attempts that have been made to increase public awareness about organ donation have not really paid dividends. Only when a family that is about to lose its loved one is approached by doctors to donate his or her organs does the message of organ donation crystallise. Until then it is only an empty thought." He said that the most distressing aspect of waiting for donor organs is that a number of patients die before donors can be found.


T.A. HAFEEZ
Dr. K.M. Cherian of the Madras Medical Mission in Chennai.

Dr. K.M. Cherian, director of the Institute of Cardio Vascular Diseases run by the Madras Medical Mission in Chennai, where six heart transplants were performed over the last four years, is unhappy that even among the medical community, there is a near-total lack of commitment to the cause of transplant surgery. He said: "It seems that 40 cadaveric kidney procedures were done last year. Surely all those 20 people had hearts. I would like to know what happened to those 20 hearts? The MGR Medical University in Chennai established a Central Organs Registry last year. How many institutions that had cadaver kidneys contact this Central Registry to say 'We have a donor with such a such blood group?' If they didn't contact the Registry, we should ask why."

According to Dr. Cherian, the reason for this apathy is "jealousy and counter-productive competition" in the medical fraternity. He said that the All India Institute of Medical Sciences (AIIMS) had stopped performing heart transplants, and added that it was probably because of lack of coordination among the neurology, accident and cardiac departments. "We are not a centre where accident or neuro cases come," he said. "We have to depend on other hospitals to get donors. We have been certified by the Tamil Nadu Government for performing heart, lung and kidney transplants and when we get a donor we are willing to extend our facilities to anybody who wants to perform a kidney transplant." (A kidney transplant procedure was performed at his institute by a team from the Sri Ramachandra Medical College Hospital in Chennai.)

According to Dr. Cherian, the majority of the 79,000-odd people who die in road accidents in India every year are potential organ donors. Apart from the reluctance of the dying person's relatives to donate the organs (organs such as kidneys, liver and heart have to be removed when the heart is still beating), another stumbling block is the requirement to constitute a panel of neurologists which has to certify that a patient is brain dead before his or her organs are removed. Dr. Cherian questions the logic behind appointing government doctors as members of these panels.

Of the six cases in which heart transplant procedures have been performed at the MMM, five patients are alive and doing well. September 23 marked the third anniversary of the first heart transplant procedure performed at the MMM. The recipient was Maimoona Beevi, a bangle seller. MMM observes this day as Organ Donation Awareness Day.



Dr. M.R. Girinath of Apollo Hospitals.

While Maimoona Beevi was the first woman on whom a heart transplant procedure was performed in India, the MMM has another first to its credit. The country's first paediatric heart transplant was performed at the MMM about 18 months ago on an 11-year-old boy who suffered from cardio myopathy. The Pallavan Transport Corporation paid a part of the costs since the boy's father was its employee. The remaining costs were borne by the MMM.

SINCE donor hearts are difficult to get, doctors have to be careful about the choice of recipients. Dr. Girinath said that he would choose patients "who have a life expectancy of less than six months without the operation." "This means that they are in an advanced stage of heart failure and there is nothing else you can do for them." In addition, the patients should not have very high pressure in the lungs and the arteries of the lungs and their other vital organs should be functioning well.

Dr. Cherian's team does not use steroids. Dr. Cherian said: "Compared to others who perform heart transplants in India, we use a smaller quantity of immuno suppressants and have stopped using steroids, which is a conventional method of treatment." According to him, non-use of steroids is the latest development in heart transplantation techniques. Dr. Cherian said that the 10-year survival rate for heart transplant patients is around 45 to 50 per cent.

Dr. P.V. Rao, a cardiac surgeon at Apollo Hospitals, who performed the transplant procedure on Subramaniam, said that despite the fact that the number of heart transplant procedures performed in India was only a fraction of those performed in the United States and Europe (each of which witnesses about 2,000 procedures a year), the future looked optimistic. "Heart surgery started in a very small way in India," he said, "but today over 50,000 open-heart operations and one lakh closed-heart operations are being done. Tomorrow, if the costs come down or some technological advance takes place, we can make rapid strides in this area."

However, until such a scenario emerges, most of the patients who need to undergo this procedure to survive will not be able to afford it. Dr. Girinath said: "We can waive the surgical and hospitalisation costs, but the biggest problem is to keep the patients going on the immuno suppressants after the surgery."