Barefoot surgeons

Meeting a remarkable individual, who performs surgery without formal training, leads doctor Neil Singh to reflect on the growing number of ‘non-physician clinicians’ in poor countries. Can they be a safe and sustainable solution to the global shortage of health workers?

Ahvaz, Iran. Ashkan Forouzani/Unsplash

Have you ever seen a house that’s also a hospital? My paternal grandparents’ home is a large, cuboid building in a walled compound, in Bihar, India. At the front is a portico where we spent much of our time during our childhood holidays, sitting on chairs of wood and wicker, while elderly locals would stop by to catch up with my grandparents. I remember that portico floor so clearly: a mosaic of broken shards and off-cuts of marble, set into concrete, a wordless monument against perfection. Against waste.

When my grandfather retired as a Professor of General Surgery at the local government university hospital, he spent more time at home, but work still came to him, whether he liked it or not. In a state where healthcare is still scarce – and, where available, often expensive – the reputation of a good surgeon travels far, and lasts a lifetime.

So it was that my grandfather – known within the family as ‘Baba’ – decided to set up a pro bono clinic at home to serve the numerous locals who still came to him begging for medical attention. It was not unusual for patients to arrive without warning, and casual conversations halted so that he could press on tummies and give advice.

Patients often returned on the anniversary of their operation, to say thanks for the care they had received from Baba. I remember one man lifting up his shirt to reveal a scar under his ribcage and holding up a pouch containing his gallstones, before tucking them back into the waistband of his lungi. He and his wife had walked nearly 300 kilometres from their village in Nepal just to pay homage to the doctor who had cut away his pain, for free.

Over the course of several visits, over two decades, I saw how the house was becoming more and more a mini-hospital: first the garage was used as an operating theatre, and then more and more rooms got built on top to accommodate growing patient numbers. There was always a small posse of staff looking after post-operative patients, who soon became as familiar as my relatives. I never asked why they were there or what exactly they did. All I knew was that they were the ones who did most of the caring for the patients before and after my grandfather performed the surgery, and were – functionally – family. One man, Lalit, stood out for his intelligence and diligence, and I assumed he was a trainee doctor, as even my father would refer to him with the honorific suffix ‘-ji’. It would have been rude to call him Lalit. He was always Lalitji.

Lalitji commanded proceedings with assuredness: spinning the forceps around his thumb and cutting as if the scalpel was in fact a sixth digit

Entering the clinic

Once, when I was 19, after spending some hours eating and chatting with my grandmother, I asked her about the clinic and she invited me to go and take a look for myself. It was an intimidating thing, even – or perhaps especially – for a young medical student. After all, this was meant to be my world, and yet it felt like another reality to what I had seen in hospitals in the UK. I walked in past a queue of patients staring at me, a strange, brown boy who moved and dressed like a Westerner. A staff member caught my eye, ushered me up a twist of concrete stairs, and then asked me to take off my chappals at a doorway. Inside, the team beamed to see me, as if they’d been waiting to see if I’d ever show an interest.

My grandfather asked me to sit with him at one side. He instructed a member of the team to bring me a bottle of mango juice, as if we were taking seats to watch a game of cricket. The team were prepping a young woman for surgery. The anaesthetist had none of the high-tech machinery you’d expect, relying on just a drip in her arm, a spinal injection to keep her pain-free, and manual measurements of pulse and blood pressure to monitor her sedation. Several women in saris came in with huge steaming pans of sterilized instruments and gauze.

The setting was basic, but the motions and mood of the people in the room were no different from any other operating theatre I’ve seen since. The patient was lain on a thin plinth as her abdomen was exposed and iodine was applied by Lalitji, wearing a white cotton gown and mask. All re-useable, of course. Even the surgical gloves would, after being thoroughly cleaned, be dried on a line and re-used. Lalitji invited me to scrub up too, with iodine soap in a modest basin, and help him with the operation.

Lalitji commanded proceedings with assuredness: spinning the forceps around his thumb and cutting as if the scalpel was in fact a sixth digit. In minutes, he had sliced through her skin and abdominal muscles, even though he was working without electro-cautery to staunch bleeding, and so had to manually tie up each and every blood vessel along the way. In one-word commands in English, he asked me to try cutting and tying knots, and though he said nothing, I knew he was disappointed that I – at the time a medical student training in the West – was so hopeless and unrehearsed. I was perspiring so much that an assistant had to mop my brow to prevent sweat dropping onto the sterile operating field.

It was no simple operation: it involved removing a diseased part of the woman’s bowel and stitching her intestines back together with a neat seam. What amazed me most of all was the efficiency of the team, and Lalitji’s resourcefulness. In the West, surgeons often use one suture per stitch, cutting the long ears of excess thread and discarding them. There, they had no such luxury; the clinic had to minimize costs and waste was not an option. So I watched him use one suture for multiple stitches, cutting knots to leave just a few millimetres of thread showing each time, eventually discarding just the curved needle with a tiny wisp of thread. The bare light-bulb above the bed went out mid-operation. During the blackout, while I was inwardly panicking, waiting for the backup generator to kick in, I could hear the sure click of the next needle being loaded onto the forceps.

It was the first of many operations where I scrubbed up to assist the team: from pregnancy terminations, to caesarean sections; from performing circumcisions, to the time I fished out a bladder stone with my fingers. On one occasion, while my grandfather was napping in the house, I asked Lalitji which medical school he had attended. He looked up and made a joke with another assistant. I asked him what was so funny. ‘I not go to medical school,’ he replied, smiling. ‘I not finish school,’ he said, waving his hands as if flattening a sheet. ‘I no read, no write.’ I was shocked. So Lalitji wasn’t a doctor after all. ‘But, then,’ I asked, in my broken Hindi, ‘where did you learn all this?’ I asked him to repeat his sarcastic answer twice, as I did not understand the first time around: ‘The University of Baba.’

A response to brain drain

It was true: Lalitji had left school unable to read and write, and yet had been trained by my grandfather to perform surgery, initially supervised, and now on his own. This was never the plan. My grandfather had dreams of his children becoming surgeons and taking over the pro bono clinic after he retired. But while they did become doctors, they emigrated to the UK and have lived there ever since. His daughter, my aunty, did remain living locally, but chose to specialize in obstetrics, a speciality seen to be more fitting for a woman in a state with traditional, gendered expectations. So, with no young children nearby to impart his experience to, he started training up his surgical assistants to do remarkable work, often independently.

But while Lalitji is no doubt exceptional, he is by no means alone. In fact, non-physician clinicians (or NPCs) – defined as health workers with more formal training than nurses, but less than doctors, who provide services that have traditionally been provided by physicians – perform a large proportion of the surgery done in the Global South. Unlike Lalitji, NPCs are usually well-educated, although often from less well-off, and more rural, families than those who end up being doctors.

In 2015, The Lancet published a report outlining the challenge of unmet surgical needs worldwide, which estimated that five billion people lack access to safe, affordable surgery, with nine out of ten people in low- and low-middle income countries lacking access altogether.

Part of the problem is the cost. Every year, the price of surgery forces a quarter of those getting surgical care worldwide – that’s 81 million people – into financial ruin. And yet, from the perspective of health systems, surgery is excellent value for money. It is estimated that the current shortage of surgical workers will cost low- and middle-income countries (LMICs) over $12 trillion (using 2010 US dollar purchasing power parity) between 2015 and 2030 in lost productivity, and is thus hampering countries from achieving broader development goals.

It has been calculated that a density of 20 surgeons, anaesthetists and obstetricians per 100,000 people is needed to deal with most of the unmet surgical need in poor countries. This equates to over a million more surgeons worldwide. This problem is especially acute in the Global South; only 12 per cent of surgeons practise in Africa and Southeast Asia, serving a third of the world’s population. But it’s much bigger than just surgery: the current global shortage of 7.2 million health workers will increase to 12.9 million by 2035. Shortfalls are greatest in sub-Saharan Africa, where just 3 per cent of the global health workforce must deal with 24 per cent of the world’s disease burden.

The reasons for this shortage of health workers in poor countries are well-known: there are not enough doctors produced in the Global South, and too many doctors leave underfunded settings, as part of a massive brain drain. Indeed, rich countries actively poach health workers that have been trained at the expense of taxpayers in poor countries – a cost-effective, if cruel, way to staff their hospitals.

Poor countries have responded by using both incentives (such as perks and scholarships) and coercion (such as seizing passports or withholding certificates required for job applications). But these have barely made a dent in the net outflow of skilled labour out of countries already short in medics to countries in the Global North. For example, over 50 per cent of doctors trained in Ghana have migrated to richer countries.

The Lancet has asked whether such South-to-North migration should be considered a crime, and there are calls for transnational agreements to stem the flow of health workers from poor to rich countries. But in the meantime, one of the main ways LMICs have responded to this drastic health-worker shortage is by plugging gaps with non-physician clinicians. I decided to find out more about what it was like working as an NPC performing surgery in one of the most understaffed regions in the world.

Second-class surgeons?

Malawi is one of five countries in sub-Saharan Africa where NPCs perform major surgery, under the designation ‘clinical officers’. Safalao Phalira is Chief Orthopaedic Clinical Officer at Beit CURE International Hospital, Blantyre, in the southernmost part of Malawi. Blantyre gets its name from the town in South Lanarkshire, Scotland, where David Livingstone – the Christian physician and explorer better known for his humanitarianism than for his problematic and unscientific views of Africans – was born. This missionary tradition remains strong at the CURE International hospital, which is one of a network of health centres throughout Africa, set up by US Christians to offer orthopaedic surgery to those who would otherwise go without.

The CURE hospital wouldn’t look out of place in the UK, with its red-brick building and tiled roof, with painted parking bays fronted by a lawn and shrubs. The operating theatres are well-equipped, with overhead LED lights and anaesthetic machines, a world away from the kind of setup Lalitji was used to. But this high-spec centre is set within a very weak health infrastructure. While in the UK a population of 100,000 would be served by about 1,000 nurses and 250 doctors, in Malawi the same population would be served by only 25 nurses and one doctor. A Malawian survey revealed that there were only 15 trained surgeons for a population of 13 million. At most government hospitals, there are about four NPCs for every full-trained surgeon. Staffing is better at charity hospitals like CURE International; the orthopaedic unit there has three fully trained surgeons and Phalira, the only non-physician surgeon.

In 1964, the British protectorate of Nyasaland claimed independence and renamed itself Malawi. In the decades that followed, Phalira’s father worked as a government clerk while the country was under the repressive rule of Hastings Banda. Phalira’s father remembered how, in all business and governmental offices, an official picture of Banda had to be hanging on the wall, and nothing could be placed higher than his portrait. Phalira was born in Zomba, 70 kilometres northwest of Blantyre, close to Lake Chilwa. When he was 12, his father left his desk job to work as a farmer, and, with his wife, raised Phalira to have a love of nature.

As a child, he wanted to follow his parents into agriculture, but as he became more educated, wondered if he could find a job to help improve the health of his people. He would have loved to have become a doctor, but at that time there was no medical school in all of Malawi, and while elite families paid to send their children to schools that prepared students to study medicine abroad, he instead enrolled at Malamulo Campus of Medical Sciences, at the Malawi Adventist University, for a three-year Diploma in General Medicine. This involved basic clinical training, and most of his fellow graduates became NPCs. It makes sense for cash-strapped health systems to encourage the training of NPCs – it’s nearly 20 times cheaper to train an NPC than a physician in sub-Saharan Africa.

Staffing shortages meant that he had no problem finding his first job as a medical assistant in a rural outpost, where he worked for five years. A desire to pursue his interest in surgery, and to have a better salary, drove Phalira to undertake two years of further training in clinical orthopaedics at the Malawi College of Health Sciences. He was trained by orthopaedic surgeons, but he says that the mentorship for non-physician surgeons is ‘not very good’, as the trainers focus their efforts on teaching the physician surgeons.

He now lives with his wife and three children, and works fulltime at the CURE International hospital. ‘Eight hours a day for five days a week, and two Sunday calls per month,’ he told me. For this he is paid about $700 per month, about three times the national average and certainly much more than the basic wage my grandfather paid Lalitji. But it’s still about half of what Malawian physician surgeons are paid. With this, he can just about manage to pay his children’s school and college fees (all education above primary school level is paid for by families).

He performs about half a dozen operations per week, mainly planned, elective procedures to treat a range of conditions – cleft lip, clubfoot, burn contractures, and the bowed legs of rickets – which, if left untreated, could lead to a lifetime of ostracism and destitution. These are by no means straightforward operations, and yet he described a situation where NPCs like him are given a great deal of responsibility early on. ‘When you have enough experience you are left alone,’ he told me, ‘so most of the time you are left alone [with no other surgeon in the room].’ In Malawi, 38.5 per cent of major general surgery is performed by NPCs working alone. The rest of the time he is fully responsible for the post-operative care of his patients, and, in addition, he runs a weekly outreach clinic for patients who live outside the city.

Phalira has a calm, straightforward manner. I asked him if NPCs get treated with respect by patients and fellow staff. ‘No,’ he told me, with neither hesitation nor bitterness. ‘We are seen as assistants.’ Phalira readily admits that there is a big difference in knowledge between physician surgeons and assistant clinicians like himself, but he says this is mainly due to ‘exposure to cases… [physician surgeons] are given priority’.

Phalira’s passion for orthopaedics looks likely to continue as he approaches retirement. He plans to engage more in orthopaedic disability projects, especially those relating to clubfoot, a congenital deformity affecting about one in every thousand births in Africa where the feet are turned inwards. It was traditionally treated with invasive surgery, but a newer, non-operative technique is more successful and can be performed by trained assistants without surgical training.

This technique, known as the Ponseti method, involves physical manipulation, together with the use of serial casting of the foot and braces to maintain feet in a more normal position. With the proper gentle manipulations and plaster casts, the majority of cases of clubfoot can be corrected in infancy within about six to eight weeks. It is a life-changing procedure, but is still underperformed, due to the lack of training of community health workers. Phalira wants to get involved with schemes to train them better, so he can help improve orthopaedic outcomes in more rural areas.

Malawi has been one of the main sites of research into the use of NPCs in surgery. It has been shown that when NPCs perform surgery in Malawi, the outcomes are no worse than that of a fully trained surgeon, when good training and supervision are provided. In Africa, 47 nations employ NPCs, and based on trends Phalira is witnessing in health education and recruitment, he thinks that ‘non-physicians will still dominate in the next 10 years’.

I knew he was disappointed that I was so hopeless and unrehearsed. I was perspiring so much that an assistant had to mop my brow to prevent sweat dropping onto the sterile operating field

Surgery in the field

The idea to use less-qualified staff in place of a doctor is hardly new. Indeed, for most of history, surgery was done by practitioners without scientific training – from Sushruta, who was performing reconstructive surgery in India around 800 BCE, to the 18th-century European barber surgeons.

From the 16th to the 19th centuries, at the height of international maritime trade and naval warfare, first British and then North American warships kept ‘surgeon’s mates’ to assist the ship’s surgeon. Surgeon’s mates provided vital pairs of hands in extreme settings, and some made pioneering contributions to medicine. James Lind – who later went on to become famous for conducting the first clinical trial (which revealed that citrus fruits prevented scurvy in sailors) – began life as a surgeon’s mate, starting work when still a boy of fifteen.

In the late 19th century, in British colonial India, the Madras Medical School allowed graduates to terminate their studies after three years – two years before the end of the full physician’s course – in order to leave and become ‘sub-professional’ medical licentiates. And many present-day medical schools of Africa began life as medical assistant training schools.

In the literary work of the Russian physician-writers Mikhail Bulgakov and Anton Chekhov, we hear descriptions of assistants, or feldshers, staffing the rural clinics across the country’s vast expanses. Feldshers, which comes from the German term for ‘field shearers’, are agricultural barber surgeons who have provided basic medical care in Russia and some Eastern European nations from the 17th century to the present day. You can read letters from feldshers in 19th-century Russia, describing themselves as ‘invisible men’, ignored by physicians and patients alike, just as Phalira describes himself today.

From the 1960s to the 1980s, as part of the Chinese cultural revolution, Mao Zedong initiated a programme of taking rural people with minimal education and training them in under six months to become so-called ‘barefoot doctors’: able to treat common ailments and promote health part-time for a modest salary, while maintaining their agricultural work.

Many Western public-health experts disdained ‘feldsherism’ and barefoot doctor programmes as backward and anti-scientific, declaring that ‘a physician treats the masters, and a peasant is treated by a feldsher’. This hasn’t stopped Western countries from devising their own schemes for training and deploying non-physician clinicians to do work that was previously done solely by doctors. There are now more than 300,000 NPCs working in the US alone. In the UK, NPCs work alongside me in primary care, in a range of roles: advanced nurse practitioners, first-contact paramedics, pharmacist prescribers and physician assistants.

The reason seems to be the same one motivating countries in the Global South: cutting costs. This is based on the hope that NPCs will: a) treat patients with similar outcomes, reducing physician workloads; b) be trained more quickly and less expensively than physicians, so reducing costs; and c) be more willing than physicians to work in medically under-served areas, so improving access to care.

In the West we tend to think of surgery as high-tech and specialist, in contrast to primary care and public health. But in contexts where primary care is weak, and where out-of-pocket payments mean that patients present to doctors late, having suffered for too long in fear at home, this separation becomes moot: essential surgery is part of primary care. This idea is promoted by the Amsterdam Declaration on Essential Surgical Care. It lists 15 types of bread-and-butter surgical conditions that, if addressed, would deal with the bulk of the unmet surgical need in poor countries. There are calls for formalized training of NPCs to deliver care for all 15 of these conditions so that they become all-rounders, able to work in even the most basic, rural setting.

But the good results of using NPCs as an interim measure doesn’t take away from the desperate need to train more specialist surgeons to be the cornerstone of surgical care in poorer settings. Some hope that the use of NPCs will help in the retention of physician surgeons, as the former would provide invaluable assistance with the routine workload, allowing the latter to focus on more complex cases.

Specialist surgeons will also be needed to train, supervise and maintain quality standards, so the roles should still be distinct. Phalira would like to see more postgraduate educational opportunities for clinical officers like him, saying: ‘Our training is not enough.’ But the reason why NPCs are needed (the shortage of doctors) is precisely the reason their oversight, training and mentorship by physicians is often minimal and rushed.

Is making-do making sense?

In LMICs, where staff salaries account for a third of total health expenditure, there is a strong drive to transfer as much work as possible from highly trained, highly paid employees to their lower-skilled, lower-paid counterparts. This process, known as ‘task-shifting’, is widely encouraged in global health circles. The 2006 World Health Report advocated increased community participation and the systematic delegation of tasks to less-specialized cadres. In the words of the WHO, task-shifting ‘presents a viable solution for improving healthcare coverage by making more efficient use of the human resources already available and by quickly increasing capacity while training and retention programmes are expanded’.

But does task-shifting yield cost savings and improve efficiency for health systems? According to a 2017 study, it ‘can help achieve cost savings and improve efficiency … but the evidence base is mostly limited to primary healthcare and community-based care’. There is now a large body of research that suggests that task-shifting can lead to improvements in access, coverage and quality of health services at comparable or lower cost than traditional delivery models.

Surgical assistants like Phalira often work in the shadows, but some have got pretty close to the spotlight. Perhaps the most prominent example is Hamilton Naki. Born in a South African village in 1926, Naki had to leave school at the age of 14, as his family could no longer support his studies. He worked as a gardener at the University of Cape Town Medical School, where his careful handiwork on the university lawns impressed Robert Goetz, a surgeon who went on to perform the first coronary artery bypass operation. Goetz asked him to help in his surgical laboratory.

To begin with, Naki’s duties involved dissecting animals to help with research experiments. But eventually his talent with his hands meant he was asked to join the transplant team at Groote Schuur Hospital by the surgeon Christiaan Barnard. The hospital gave Barnard permission to work with Naki, but as apartheid laws forbade black people from cutting white flesh, the team had to keep his role a secret for over 30 years. In December 1967, Naki was part of the team conducting the world’s first heart transplant: while Barnard removed the recipient’s diseased heart, Naki was in the next room harvesting the still-beating heart from the brain-dead donor. While Barnard became an overnight celebrity, it was only long after apartheid had ended that he acknowledged Naki’s contributions in an interview shortly before his death.

The recent rise of NPCs seeing patients – in both rich and poor countries, often with minimal oversight – raises some very uncomfortable existential questions for doctors. Might there be reason to see the use of NPCs, not merely as an intermediary stop-gap measure, but as an altogether different and, in fact superior, form of healthcare delivery? Historically, the medical profession has been elite and focused predominantly in urban centres. In contrast, NPCs tend to work closer to the areas they live in, have a different class-character, and are far more likely to remain in the countries they train in than doctors. The experience of utilizing NPCs to help deliver antiretroviral therapy to curb the HIV/AIDS epidemic in sub-Saharan Africa has taught us that NPCs can dramatically enhance community participation, if they are genuine representatives of their communities and give voice to lay and local concerns.

The use of NPCs has the potential to reshape medicine, and perhaps medics themselves. Once we rid medical institutions of the biases and recruitment practices that favour urban elites over the rural, working classes, we might see that our future medical workforce resembles more closely the populations they serve, improving the retention of staff and the availability of care in even poor parts of the world.

But, even if we were to find that complication rates are higher when people are treated by non-physician clinicians compared to fully qualified doctors, we must remember that for patients in low-resource settings, the outcomes are still far better than they would be in the absence of any intervention altogether. For now, the tension between pragmatic and idealistic approaches to global health staffing looks likely to continue. Sometimes making do is better than doing nothing at all.

There are legitimate concerns that nonphysician clinicians are replacing trained doctors, reducing their growth in regions where they are most desperately needed

Concerns about task-shifting

Task-shifting is usually associated with left-leaning governance and progressive politics. After all, it was Third World countries in the early postcolonial era who were the primary proponents of scaling up ‘community health worker’ schemes. The Alma Ata Declaration, born out of the International Conference on Primary Healthcare in 1978, set a goal of ‘Health For All’. To achieve this, the use of community health workers was crucial to the WHO’s strategy, as they were the most realistic and appropriate way to meet the stark human resource shortages in poorer nations.

But there are also progressive arguments against task-shifting. In 1976, during a talk on the shortage of primary care doctors, Milton Terris, an American professor of Community and Preventive Medicine, launched into a stinging critique on the then-new vogue for utilizing physician associates, saying that ‘feldsherism... is the epitome of class discrimination’, as the use of NPCs can create a two-tiered system. Patients fear this and it is not uncommon for patients in the UK to explicitly request a doctor, to avoid the seemingly ‘second-class’ care of one of my NPC colleagues.

The success of NPCs depends on whether they are used as a supplement to or a substitute for doctors. There are legitimate concerns that, instead of being used as an adjunct to boost health worker numbers until such time as we train enough doctors to cover the world equitably, NPCs are replacing doctors, reducing their growth in precisely those regions where they are most desperately needed. Getting the right balance between doctors and NPCs – in terms of ratios and division of roles – will be crucial if their use is to remain effective and accepted.

There is sometimes a tension between the desires of clinicians (to use NPCs in addition to doctors in order to help take healthcare to people and places it currently does not go) and policy-makers (to replace doctors, to reduce costs). For me, the crunch question is this: ‘Is using NPCs in this context helping the growth of an adequate, sustainable supply of fully trained physicians, or is it instead slowing that process?’

The aim of using NPCs is to help redress the health disparities common in poor countries, especially in rural areas. But it can be argued that by having one acceptable ratio of doctors in rich countries and another in the Global South, health inequities may be re-entrenched. Some public-health ethicists have argued that task-shifting does nothing to dismantle the structural barriers that separate marginalized people from conventional healthcare systems and may inadvertently harm already vulnerable populations by normalizing substandard care and delaying the arrival of high-quality, comprehensive healthcare services.

Most discussions on task-shifting take the shortage of fully trained doctors as a given. But does it have to be this way? Why don’t we just train up more doctors until we have enough? This is the approach adopted by Cuba, which lost about 40 per cent of its physicians shortly after the Cuban Revolution, but then proceeded to go all-out in training physicians. In 2018, Cuba had one physician for every 120 people.

Phalira agrees that more fully trained physicians is the ideal solution for countries like Malawi. ‘We need more doctors,’ he said. ‘That extra training makes a big difference.’ Spending on health workers should be seen as an investment rather than a cost. But he reminded me that ‘even a doctor is no good if they don’t have the facilities.’ The use of NPCs only makes sense alongside investments to ensure better health infrastructure and broader social goods to prevent illness and promote welfare.

We who hold the blade

When my grandfather died in 2013, it was Lalitji who attended to him, trying to open his airway with a laryngoscope and performing chest compressions that didn’t work. I flew to India as soon as I could – too late to attend his cremation by the Ganges, but in time to take part in some other ceremonies. One of the rituals involves all the male relatives shaving their heads. This was done at a serene spot beside a small lake with tall trees on its margin. Of the eight male children and grandchildren my grandfather had, five of us had become doctors, and all five of us were practising in Britain. This is what brain drain looks like at the level of individual families.

All the men who worked at my grandfather’s clinic also volunteered to have their heads shaved, out of devotion and reverence for their late mentor. The overall mood was of sombre heartbreak, and not just regarding the loss of an individual; it was unclear how the clinic could continue without the only trained doctor they had. Due to the lack of any medics to supervise Lalitji and the other staff, Baba had – out of necessity as much as out of dedication – kept working and operating into his nineties. On my last visit while he was still alive, Baba confessed to me that once-routine operations were becoming ‘tiresome’, and yet he had no choice but to keep working. Even when he was shuffling with a cane to get to the operating room, and had to sit to work, his mind and hands were still working well enough to allow him to operate safely.

We sat on the ground and, one by one, had all the hair on our heads shaved by a local barber, using just a bare razor blade and water. Standing around waiting for the last of us to be shaved, I spoke to Lalitji, who told me he wasn’t sure what to do next. For now, he would continue to work as the lead surgeon, but how long could he do that, without any further training or supervision? I had no doubt that his skills, experience and innate gift meant that he would be able to continue working as a surgeon, but was such an arrangement good for his patients and for him?

But then, while we wait decades for the shortfall in health workers to be filled, what are we to do with the abundant health needs we see around us, especially in the Global South? As problematic as task-shifting may be, it seems hard to imagine a future without NPCs, doing what they have always done: making-do the best they can. But it is perhaps even harder to imagine a way of weaning ourselves off their cheap and efficient care once we get used to it. And this is not just a problem for our world’s poorest countries; all nations will have to grapple with how best to staff health systems in a way that is affordable, feasible, equitable – and safe.

As I got on the plane to fly home, I saw a new reflection in the blank seatback screen. I was thinking of my grandfather, and Lalitji, and then all the barriers – language, culture, practicality – that meant it was him, and not me, now in charge of the clinic. This thought filled me with a feeling of relief, followed immediately by guilt and shame. I looked out at the runway, restless, as the seatbelt lights went on and the flight attendants ran through the safety instructions. With the tray-table folded up, for a while I fidgeted as if trying to solve an impossible Rubik’s cube. Eventually I decided to sit on my hands. I could not bear to look at them.

Neil Singh is a primary care physician, and a senior teaching fellow in the Department of Primary Care and Public Health at Brighton and Sussex Medical School. His writing on health has featured in the Guardian and The Independent.