‘A letter to 4,000 children with a scar on the chest’ 

"When God sent you to this world it was the best thing that had happened to your parents. Unfortunately, their happiness was short-lived. That very day you started turning blue in colour; the doctors had found a hole in your heart.Your parents could not afford the cost of your heart operation. Yes, when you were 10 days old you had a price tag on your life.Time was running out and your daddy was getting desperate until he came to know about me. The first thing he told me when we met was: “I heard you love children”. Yes, I love children and have four of my own. My profession is giving hope to people suffering from heart diseases — I am essentially a technician who can cut and stitch people’s hearts; they call me a heart surgeon.” This is the beginning of a long letter from Dr Devi Shetty to 4,000 children, all former patients at one of the hospitals he had set up. Intrigued by the idea of a doctor who not only provided free treatment to poor children, but also wrote to them years later, we set off to seek out the man behind the words. We wound up on the outskirts of Bengaluru, and left behind the noisy traffic on Hosur road to enter an oasis of calm. People were milling about, carrying lines of anxiety on their faces, but hope in their eyes. The place we entered had the sounds of vedic chants wafting on the air and we were greeted by a beautiful engraved statue of Vishwarupa — the form that Krishna revealed to Arjuna during his lecture on the Gita. Despite this templelike atmosphere, it was clear that we had entered a hospital, as the doctors and nurses scurrying about showed us. We were at Narayana Hrudalaya to meet the heart surgeon whose story has inspired doctors all over the country. As we walked through different corridors in the hospital, the chants were sometimes replaced by the sounds of an FM radio like God because he was the one who could save our parents’ lives.” He once overheard his mother talking to a relative. She was blessing another woman for giving birth to a wonderful son, a doctor who had saved someone’s life without taking money. The young Devi resolved that he too would grow up to be a son that people would praise and bless his mother for. The seeds were sown early, but the moment of epiphany came in 1967, when a South African surgeon called Christiaan Barnard performed the first successful human heart transplant. Listening wideeyed to this news in a classroom in India, 14-year-old Shetty was inspired. “I made an immediate connect and decided to become a heart surgeon even before I decided to become a doctor,” laughs the man who now has many ‘firsts’ to his own credit. Shetty went on to pursue medicine and channel and at other times by the voice of Kishore Kumar. “The doctors all like to play different music when they operate. I prefer calm, spiritual music, but I let everyone create the atmosphere that suits them when they work”, says the lean and dynamic man who meets us at the door. And with that, the conversation is on.

THE INSPIRED IDEALIST

Devi Prasad Shetty was the eighth of nine children, born to parents who were already getting on in years. With a mother needing surgery and a father who sometimes went into diabetic comas, Shetty remembers that, “As kids we thought the doctor was even though, by his own admission, he was not a brilliant student, he never let go of his central desire to operate on the heart. “I couldn’t dream of getting training as a heart surgeon in India in those days — there were hardly any centres and even the teachers were learning to do heart surgery at that time. Grafting had just started and even in England, not many people were doing bypasses. So I had to go abroad,” says the man whose steps finally led him to Guy’s Hospital in London. In England, surgeons would not see patients before or after operations, since other teams were assigned those tasks. Shetty focussed entirely on honing his skills by doing hundreds of procedures, enjoying each one — even going so far as to operate on weekends. This prompted his colleagues to dub him the ‘crazy operating machine’. Practice makes perfect and Dr Shetty was soon getting the recognition that was his due as an excellent surgeon. But medical procedures were not all that the young doctor was learning. As an intern in England, he was exposed to the dramatic changes taking place in the National Health Service at the time. Cost efficiency was receiving a lot of attention as public services began to go through greater scrutiny. Even though he was not directly involved, Shetty saw that controlling costs was a vital aspect of delivering healthcare and years later, would use this knowledge when facing similar problems in India. Dr Devi Shetty was already set on his path in life — he had a job, he had skills that could bring him fame and fortune, and he had a goal. But there was a tradition in his family that those who went abroad to study finally returned to India, and his wife was keen to head home too. At the very time when he was on the horns of a dilemma, fate took a hand in the form of an offer to start the BM Birla Heart Research Centre. Dr Shetty was on his way to Kolkata, and that marked the start of different sort of journey.

FROM HEATHROW TO HOWRAH

Thirty-six-year-old Shetty came back to Indian shores in 1989 as Director of the BM Birla Hospital, and the medical facilities available in Kolkata at the time were a world away from those he was accustomed to. It took him a while to adjust to what he could and to reform what he could not accept. He remembers, “There were no disposable gowns, gloves or drapes. Sterilisation did exist, but people were re-using things and materials were not available. Nurses didn’t know how to care for patients after surgery because hardly any cardiac surgery was done. So I got a few nurses from Guy’s Hospital to train them; they stayed for nearly two years till we completed the first hundred cases.” Almost immediately upon his arrival in Kolkata he set up a paediatric surgical care unit and set a new landmark — he became the first Indian to perform open-heart surgery on a nine-day-old baby. This was at a time when people in india were just getting used to the idea of heart problems in newborns and his achievement was lauded far and wide. Far away in Karnataka, his sister called out to his mother and she came running to see her son on television for the first time, surrounded by the infant’s family members. Devi Shetty had achieved his childhood ambition to make his mother proud. Coming back to India also marked a departure in his functioning as a physician. Unlike in England, he was not just an ‘operating machine’. He had to meet patients and their families before and after the procedures; he had to face their financial concerns and see the tension on their faces. The surgeon isolated from the suffering was replaced by a doctor who saw the pain of people who were unable to afford good healthcare. He himself puts it best when he says, “It was quite traumatic when I had to start off. If there was a problem during the surgery, what came to my mind were the faces of the wife and children. You try to think of yourself as a kid and think that if something had happened to your father, you would have been virtually on the street. So these things brought in a lot of pressure. But after a while I started enjoying it because this is one of the few professions where you get the chance to become a hero in real life.” The more people he treated, the more Dr Shetty started to ponder the larger questions of healthcare in the country and its impact on ordinary people. Perhaps it was serendipity that resulted in a meeting that set the seal on his convictions — in 1990, he became Mother Teresa’s doctor, a role he was to play for the rest of her life.It started when he was asked to do a house call to see a patient, something surgeons don’t usually do. But he was told, “If you visit the patient, it may transform your life.” Meeting Mother Teresa literally did, as new and exciting things began to happen in Dr Shetty’s life. One day, she saw him examining a blue baby and said, “Now I know why you are here. To relieve the agony of children with heart disease, God sent you to this world to fix it”. To Devi Shetty’s mind, this was the best definition ever given of a paediatric cardiac surgeon; her simplicity and practical approach to life’s problems and their solutions inspired him. Little wonder then, that his office still carries her image.

MAN ON A MISSION

“The health problem of India is not a health problem, it is an economic problem. There is a solution, but it is not affordable. And if it’s not affordable, it’s not a solution.” These pithy sentences sum up Dr Shetty’s assessment of healthcare not just in India, but the world over. He finds it unacceptable that 100 years after the first heart surgery, less than 10 per cent of the world’s population can afford the operations. And this knowledge spurred him on to a spate of activity that has not abated even after two decades. After getting the Birla Hospital up and running in Kolkata, he moved to Bengaluru in 1997 and started the Manipal Heart Foundation. In 2001, Shetty founded the 1,000-bed Narayana Hrudayalaya, which offers many services apart from cardiac surgery. Next door to Narayana, Dr Shetty built a 1,400-bed cancer hospital and a 300-bed eye hospital, which share the same laboratories and blood bank as the heart institute. In December last year, the low-cost healthcare chain inaugurated Asia's largest paediatric hospital in Mumbai. He also founded the Rabindranath Tagore International Institute of Cardiac Sciences in Kolkata. Shetty is fond of saying that “You have just one life and it should touch the lives of as many people as possible”, an idea that he tried to execute in many different ways. He realised that only one per cent of his patients needed surgical intervention. So with the help of the Indian Space Research Organisation he started telemedicine facilities for remote locations via satellite. At last count, he and his doctors had treated more than 55,000 heart patients. Using satellite technology, they also treat patients in 56 African cities. By slow degrees, the ripples spread further. In 2003, Shetty worked with the Government of Karnataka on Yeshasvini, the cheapest comprehensive health insurance scheme in the world. It started at `5 per month (with the government putting in a share of the premium) and today runs without government help at `15 a month. A boon to the farmers, it had 80,000 subscribers in the first year itself. Today 2.5 million people are covered under the scheme and Tamil Nadu and Andhra Pradesh have also adopted it. But all these initiatives are just the tip of the iceberg. With his eyes fixed firmly ahead, there is much more afoot. The plans for Narayana Hrudalaya also include a trauma hospital and an ophthalmology hospital. These are the beginnings of the Narayana Health City, which will include a centre for neurosciences, a children's hospital and a cancer research centre. Health cities are also being planned in Manipal, Gujarat and Rajasthan. With affordability as his mantra, he is planning a low-cost hospital in Mysore, using natural air and light and no air conditioning, but with a fully functional operation theatre. With that, he hopes to push costs of heart surgeries down to within `55,000. Dr Shetty’s near-impossible success rate attracts patients from Africa, South-east Asia, the Middle East and increasingly, from Europe and the US as well. His latest venture is a $2 bn health city in the Cayman Islands, his first international project, that he believes will be a game-changer for the developed world. Once again, the logic behind the move is simple and visionary at the same time. “If you want to transform the way that healthcare is delivered in this world, you have to make Americans change the way they do it. Because once they set new standards, that becomes a standard all over the world. You can’t bring about any changes inside the American boundary. So the nearest country which can be used as a beta-site is Cayman Islands. And we have received close to 1,000 applications from US doctors who want to work there!”

YES WE CAN

Over the years, Dr Shetty has built a huge network of supporters, admirers and friends. At various times, the members of the board have included K Dinesh (co-founder, Infosys) and Kiran Mazumdar-Shaw (Biocon). Krishna Kumar of the Tata Trust helped to start the hospital in Kolkata, a venture for which K V Kamath of ICICI gave him the first loan. Recently, Chief Minister Narendra Modi has also given his company a plot of land to build a health city in Ahmedabad. But this was not the case when he first started to put his ideas on the table. Sometimes the greatest sceptics were the doctors themselves. When he started the Manipal Heart foundation, doctors scoffed at his statement that they could do 10 surgeries a day — at the time they were doing that many in a month. Today, they do 12-15 surgeries a day. Now when he sets targets of 50 surgeries a day, the usual response is, “How?” When he first proposed the idea of health insurance at `5 a month, no company wanted to touch it; today there are people willing to partner with him in the venture. Over time, the scope of his ambitions has begun to seem less like the notions of a dreamer and more the stuff of social revolution. India requires 2.5 million heart surgeries a year and only 90,000 are done on the people who can afford to pay, leaving the majority in the lurch. Shetty laments the fact that a country which produces the largest number of medical personnel in the world should have the healthcare indicators that we do. Visibly animated, he says, “We should be ashamed of these things. It has nothing to do with lack of resources or poverty. Our healthcare is in a mess because of poor policies. They have to understand that there is a solution out there and they should utilise that. Because ultimately what matters is that the poor patients get help.” Dr Shetty concedes that increasing healthcare spending may be difficult, but offers a way out. For him, it all boils down to a change in policy. He believes that if entrepreneurs are encouraged to step into the healthcare sector, it will offset any perceived loss of revenue to the government. For instance, new hospitals with tax exemptions would encourage entrepreneurs to build more. Analysing the situation, he realised that a lot of problems stemmed from the “refusal to think big” that seems to be the bane of policymakers in the country. He saw that with the second highest population in the world, coming up with a 100-bed hospital would only be a drop in the ocean. So, when others spoke of hospital capacities in the hundreds, Shetty spoke in the thousands. When they spoke of a health centre, he spoke of a health city. He has slowly shown not just those who work with him, but the world at large, that increasing the capacity of hospitals and amount of work done in a day reduces the amount that people have to pay. As he says, “I remember talking to a cardiac surgeon who thought that in a few years we'd be able to charge `2.5 lakh for an operation. We have reversed that ambition.” (When he started his work in Kolkata, heart surgeries cost `1,40,000. Today, the same operations cost `75,000).

THE BUSINESSMAN-DOCTOR

“The transformation to offer high-tech healthcare to everyone on the planet can not come from heaven. We have no choice but to bring about change. You can call it business practice or social commitment. One thing we do believe is that charity is not scalable. If you do something free, you will do it up to a point and then stop. Money has to come from a good business model which makes things affordable. And that is scalable.” These are astute words from the man who won the Ernst & Young Entrepreneur of the Year award in 2003 and The Economist Innovation Award for best Business Process in 2011. His ideas on the business of healthcare form a subject of study for MBA students at the Harvard Business School. With 14 hospitals in 11 cities and many more in the pipeline, he has certainly tackled the issue of scale. But as often happens, that raises the twin spectres of quality and accountability. Since he cannot personally be everywhere at all times, keeping track of the daily workings of all centres takes some doing. At such times, technology is his best friend. All administrators get a daily SMS stating the profit and loss (PnL) accounts of all hospitals. They also get reports on the mortality, morbidity and other problems. They have a system where people can call a number and report any shortcomings they observe — from unclean bathrooms to negligence by the staff, all complaints get registered in a central log. Not only does this make people accountable, it gives Shetty an idea of the areas that need improvement. At the end of the week, each department gets a note listing the complaints concerning them. Then, fresh targets are set. No detail is too small to escape this able administrator, who checks the PnL statements of all hospitals in his car on the way home from work. As he says, “We run the hospital with a wafer-thin margin. By looking at the PnL account on a daily basis, you can take remedial measures. Looking at the PnL account at the end of the month is a post-mortem report.” One example of the standards he sets was his handling of the matter of bed sores, a common ailment with post-operative patients. The global average for bed sores ranges between seven per cent and 40 per cent. Three years back, Narayana Hrudalaya launched a programme to eliminate bed sores. The nurses took personal responsibility to ensure this goal was achieved. Now, there are zero incidents of bed sores. Perhaps no other hospital in the world can lay claim to such an incredible achievement. In a testament to good management skills, this was accomplished without spending more or hiring new staff. Unsurprisingly, the attrition rate in his centres is almost non-existent. Only one senior doctor has left the organisation in all these years, and that too, for personal reasons. Healthcare as an industry is sensitive to numbers. The more surgeries his doctors and nurses get under their belts, the more efficient they become. By setting up teams specialising in particular procedures and streamlining the process, he has ended up posting respectable profits — all the while offering cheaper, and sometimes free, healthcare to the poor. His family-owned business group reports a 7.7 per cent profit after taxes, slightly above the 6.9 per cent average for a US hospital, according to American Hospital Association data. Narayana's 42 cardiac surgeons performed 3,174 bypass surgeries in 2008, more than double the 1,367 the Cleveland Clinic, a US leader, did in the same year. Obviously, this surgeon has his management and leadership skills all stitched up. MATTERS OF THE HEART Many of Shetty’s working decisions stem from his personal convictions. Perhaps no other section of society touches Dr Shetty as much as women and children, especially those who are impoverished. The man who can’t see mothers cry over sick children admits, “Surgeons are not supposed to show their weaknesses, but I sometimes find it hard to control myself.” Little wonder, then, that his sense of social responsibility extends beyond the medical. Going around Narayana Hrudalaya, we are struck by the preponderance of women guards and drivers MATTERS OF THE HEART Many of Shetty’s working decisions stem from his personal convictions. Perhaps no other section of society touches Dr Shetty as much as women and children, especially those who are impoverished. The man who can’t see mothers cry over sick children admits, “Surgeons are not supposed to show their weaknesses, but I sometimes find it hard to control myself.” Little wonder, then, that his sense of social responsibility extends beyond the medical. Going around Narayana Hrudalaya, we are struck by the preponderance of women guards and drivers not for us.’ So the aspiration is lost.” Of all the surgeries performed at the Hrudalaya, 50 per cent are done on children, and half of those free of cost. Dr Shetty has personally performed over 15,000 heart operations. He supervises organisations scattered all over the world. He starts early and through the course of the day, puts in over an hour of exercise (surgeons need to be fit), meets countless patients, talks to the media, squeezes in at least one surgery a day and also travels extensively. This would be more than enough work for 10 people to handle, leave alone a single practising doctor. So what has kept the fire burning for Devi Shetty for the past 22 years? “The confidence that India will become the first country in the world to dissociate healthcare from affluence. Ten years down the line we will have a scenario where people will still live in slums with no amenities, but when they are unwell, will have access to high-tech healthcare with dignity. Western countries have proved that a rich country cannot succeed in offering healthcare to the citizens. We’re a poor country, but within our means it is possible to offer healthcare to everyone.” As we leave Dr Shetty after spending over an hour with him, we can’t help but go back to the closing lines he wrote to the ‘4,000 children’ his centres have helped: “I clearly remember your mother’s face when she was handing you over to us. She kissed you and looked at my face with the expression of a person handing over her most precious possession. It was a different sort of love triangle between your father, mother and myself, with you at the centre. It took me six hours of intense concentration to operate upon your heart and many sleepless nights before you started smiling again. One day you will become an adult and probably a very important member of our society. All I ask is, can you spare a few moments of your precious time everyday for someone who needs it? To save your life, a few hundred people worked sincerely without expecting any remuneration other than the joy of making your family and friends happy? And when you do your work just for the joy of brining happiness to others, you’ll realise it is not your hands which do the job, it is the hands of God.”