The Imperative of Training Manpower in Liver Transplantation

Dr. Samagra Agarwal

Hepatitis, a leading cause of liver cancer and liver disease, is a major public health concern that claims thousands of lives every year. Despite its prevalence, hepatitis remains a largely silent epidemic, with many cases going undiagnosed and untreated. Hence, there is an urgent need to amplify the voices of those affected, raise aware-ness about the importance of testing and treatment, and accelerate efforts towards a world where hepatitis is no longer a threat to public health.

Less than half of the patients with decompensated cirrhosis of liver are likely to survive for 5 years after their diagnosis, and most of them are candidates for liver transplantation. Liver transplantation significantly improves long term survival in these patients, adding atleast 10-15 years to their life. However number of liver transplants remain much lower than required, with approximately 35,000 liver transplants performed world-wide annually. Thus, less than 1% of patients requiring liver transplant actually get one, with more than 99% continuing to wait, or worse, suffer. In India, decompensated cirrhosis is sparse, but is conceivably similar to rest of the world. The liver transplantation scenario is however quite different, with the majority (more than 80%) of transplanted livers being obtained from living donors, which is quite different from Western countries where upto 90% of livers are obtained from deceased donors, a much simpler surgery. Further, the vast majority (95%) of 2500 liver transplants in India annually are performed in private health care facilities. While the private sector remains the primary source of health care for two-thirds of Indians, the deplorably low rate of liver transplants in the public sector hospitals seals the prognosis for middle class patients who cannot afford the exorbitant costs of care in private hospitals. The lack of liver transplants in government hospitals has been attributed to multiple reasons, including lack of trained manpower, poor infrastructure, reluctance of relative of brain-dead donors to agree for organ donation, lower incentives for surgeons to undertake a complex surgery with uncertain post-operative course and bare minimum systemic support for families of patients in the perioperative period. While most of these problems are not insurmountable, with some states like Tamil Nadu making considerable progress, the fact remains that most patients referred to public hospitals for liver transplantation will probably never get one.

 Liver transplantation is a complex surgery; however a lot has to be done before the patient gets anywhere close to the operating table. Most established transplant centers worldwide have a team of few dozen individuals dedicated towards achieving optimum results of liver transplantation. This includes transplant surgeons, hepatologists, anesthesiologists, ICU doctors, nurse coordinators, dieticians, pharmacists, counsellors, psychiatrists, social workers and financial navigators, which help the patient and their family to get through the complexities ensuring the best possible outcomes. Unfortunately, ensuring availability of such trained manpower in public sector hospitals is not easy and requires immense administrative will and effort. There are few training programmes at present in India that focus on creating such manpower, and most of them are trained in house in already established centers, which are often absorbed there itself, further limiting the opportunities for new centers. National Organ & Tissue Transplant Organisation (NOTTO) has taken a lead in training transplant coordinators at multiple hospitals. However, the translation of their work into increasing liver transplantations remains to be seen. The fact remains that in absence of a dedicated team effort, it is impossible for a single individual to bring about significant change in the health system, and lack of systemic support is unlikely to make their job easier. There is a need for concerted effort for administrators to train trans-plantation teams, which can rapidly establish liver trans-plantation in public sector hospitals, leveraging the vast investments already made into their infrastructure.

 There is also a need to explore the barriers to deceased organ donation to make inroads towards equitable, subsidised, and accessible transplantation services in public sector hospitals. The barriers are not only cultural due to lack of awareness and acceptability of organ donation, but also legal, with lack of legal validity of donor pledge, no presumptions in favour of organ donation, and strict guidelines for brain death declaration as given by the Transplantation of Human Organs Act (THOA) 1994. Lack of education among ICU doctors regarding the THOA regulations, absence of trained multiorgan retrieval teams and transplant procurement managers, lack of facilities for rapid organ transport and poor transparency in organ registries and waiting list between the hospital and the authorities makes the task even more difficult. Until these concerns are adequately addressed, and steps are taken to develop a robust national protocol for brain stem death, educate and train multiorgan retrieval teams, and develop infra-structure for rapid organ retrieval and transport, the rates of deceased organ donations will continue to be dismally low.

Finally, there remains the need for financial support of patients and their families who are currently forced to bear a large proportion of the costs of medications, travel, wage-loss and basic care even in public sector hospitals. While public health spending in India has increased over the past few decades, reaching 2.1% of GDP in 2023, it is nowhere close to developed countries, where it is consistently more than 10% of annual GDP. In absence of primary wage-earner and with more than two thirds of healthcare costs borne out of pocket at present, liver transplantation in public sector hospitals is unlikely to become a viable option for most patients. There is a need for trained financial navigators and social workers who are aware of the national and state programmes currently supporting liver transplantation, and who can communicate them to the families of patients to make the treatments financially viable and less harsh.

To conclude, the journey for patients with decompensated cirrhosis of liver is not easy, with most of them facing immense suffering not only medically, but financially and socially. Liver transplantation has been shown to be consistently cost effective due to the remarkable survival gain compared to other treatments, and there are some successful examples which can be emulated throughout the nation. Training of effective liver transplantation teams is the need of the hour, and they cannot succeed without consistent administrative will, streamlining deceased organ donation and support for the patients and their families.

Career Options in Hepatology

The field of hepatology is ever growing field with multiple job opportunities. To start with, one can pursue specialisation after their M.D. in Internal Medicine and become a Hepatologist. If surgery is where your heart is, one can do MCH and become a Transplant Surgeon and save lives. There are dedicated Anasthesiologist who work in collaboration with Hepatologist and Transplant surgeon, so after completing MD. Anaesthesia, one can opt for the branch. Dedicated Basic and Translational research is always need of the hour so One can become a Scientist in field of Liver Disease or research on deadly viruses like Hepatitis B and C, and voila, you never know you could make a breakthrough discovery and help in eradication of these viruses. Dedicated diet is prescribed to people who suffer with liver disease so one can opt for special nutritional courses post their graduation or post-graduation and become a specialist in that field. Lot of field work is needed for creating awareness about various public health problems associated with liver disease an special public health nurses do that. Substance abuse is grave concern among our youth and is a major cause of liver disease, psychological counselling and behaviour counselling plays an important role in preventing these so a graduation or post-graduation in psychology could help you make difference in someone's life. Opportunities are endless one should make a conscious decision and work towards their goal.

Dr. Vaishali Bhardwaj, Prof. and Head, Gastroenterology, RML Hospital, New Delhi

(The author is Asst. Prof., Gastroenterology Deptt. AIIMS, New Delhi. Feedback on this article can be sent to feedback.employmentnews@ gmail.com)

Views expressed are personal.