In late December 2024, InterSurgeon spoke with Dr Milind Chitnis, an InterSurgeon member, for whom “global surgery is not even my passion; it is my mission”. From India to Scotland to South Africa, where he has worked for the past 30 years, Dr Chitnis is a product of what successful global surgical partnerships can create to promote universal healthcare coverage.
The beginning
Dr Chitnis grew up in various towns and cities within the Maharashtra State and studied and trained as a General and a pediatric surgeon in Pune and Mumbai, India. “I worked at the Sassoon General Hospital, affiliated with the B J Medical College, University of Pune, for three years from 1990 to 1993. Professor Daniel Young (one of three Professors of Paediatric Surgery in the UK at the time, based at the Hospital for Sick Children, York Hill, Glasgow, Scotland) visited India, Mumbai, and Pune in 1992. I met him there, and he asked me whether I wanted to train in their unit for a year. That changed my whole destiny because I went to Glasgow from Pune. I thoroughly enjoyed it, even though it was quite a cultural shock because I had worked at the Government Hospital in Pune, India. We had only four cots in the female surgical ward for children. I worked in the general surgery department of a paediatric surgery firm. So, at least, I was working with a paediatric surgeon, but there were no special facilities. We had no ICU, no parenteral nutrition, no ventilators, nothing! From there, I went to Glasgow, where there was a 20-bed neonatal surgical intensive care unit. The name of that unit was the Daniel Young Neonatal Surgical Unit because Daniel Young had worked hard to get it. So, it was a huge jump in learning for me. The weather was completely different from that in (warm) India. I come from a central part of India, usually quite warm, followed by the cold, misty, and rainy Glasgow. But the people, including the doctors and the nurses, were genuinely nice and welcoming. So that helped a lot.”
Fig 1: The Hospital for Sick Children, Yorkhill, Glasgow, Scotland
From India to South Africa via Glasgow
His son was born in Glasgow, and he met his next mentor, Dr Colin Lazarus, a General Surgeon born in the Eastern Cape province, South Africa and trained in the UK and South Africa. Dr Chitnis says, “He was a locally grown general surgeon, and he decided to specialise in paediatric surgery quite late in his career. He was head of surgery at the Cecilia Makiwane Hospital in Mdantsane township, later a suburb of East London. Dr Lazarus spent one year in the Red Cross War Memorial Children’s Hospital in Cape Town and the second year at the Hospital for Sick Children at Yorkhill, Glasgow. He was working at a higher level because he was already a registered general surgeon, even in the UK. He was given a locum consultant position and worked as a senior registrar. I worked at a Senior House Officer level and learned much from him. Halfway through the year, he told me he was returning to his hometown- East London- in South Africa and starting the new paediatric surgery department there. If I wanted to join him, he could telephonically arrange my registration with the medical council and the job interview.”
At the time, in Glasgow, there were many South African doctors training in different departments, not just paediatric surgery, so Dr Chitnis asked around and then: “We just took a leap of faith and came to South Africa; like we completed the triangle from India to Scotland, Scotland to the tip of Africa. And here we are, 30 years later! The department my ex-boss and I started with only two people has grown. It is now a nationally and internationally recognised Department of Paediatric Surgery. My ex-boss was quite visionary. He wanted to start a regional paediatric surgery service. We have successfully established a regional Paediatric Surgery Service, of which we are immensely proud.”
Fig 2: Map of South Africa showing the Eastern Cape Province and East London
It was towards the end of systemic apartheid in South Africa that Dr Chitnis was given a job at the Cecilia Makiwane Hospital in Mdantsane, which is the second largest township in South Africa, situated initially in the “homeland/separate country within a country” of Ciskei, where local Black politicians ruled over the poor Black people. “The Cecilia Makiwane Hospital, where we started working, served the poor Black population. It was initially run on missionary principles, although it was not a missionary hospital. They named it after Cecilia Makewane, the first black nurse from South Africa. The then Ciskei government built the Cecilia Makiwane Hospital in 1976 in Mdantsane, now a suburb of East London. It was serving all the poor and needy Black people. There were some local South African doctors, all committed, dedicated, and quality-conscious, and many expatriates: Europeans, Filipinos, Indians, Pakistanis, etc. My ex-boss arranged for me to get registration through the Ciskei Medical Council.” Despite being a qualified paediatric surgeon, Dr Chitnis faced numerous challenges due to his foreign qualifications. He was only given registration to practice as a Medical Officer, equivalent to a senior SHO, and was initially on a work permit. It took eight years, until 2003, to get permanent residency. He gained permission to write the College of Paediatric Surgeons exit exam only afterwards. After he cleared that exit exam, his registration was still only for the public sector and for working in the state hospitals. He subsequently had to write the final MBChB examination, which he did in 2008-2009, to get registration for independent (unsupervised) practice. These challenges, however, did not deter his determination to serve the community.
Fig 3: Original/”old” Cecilia Makiwane Hospital
Fig 4: Frere Hospital
Fig 5: “New” Cecilia Makiwane Hospital
Building a department in the Eastern Cape Province
South Africa has a dual healthcare system; the state hospitals are subsidised by the government and serve 88% of the poor Black population. Only relatively more affluent 12% of people have medical insurance called “medical aid”, which allows them access to healthcare in the private sector. Most state hospital patients, Dr Chitnis describes, survive on the country’s social security system. There are many adolescent pregnancies, which means childcare often falls on the older members of the family; “I would say 95% of our patients in the state hospitals where I work predominantly, they are people of Indigenous African origin, black people, most of them live in rural areas and the majority of them survive on social security. Luckily, the social security network is decent in South Africa, which is not as good as the UK or other Western countries, but it is better. It is much better developed than other middle-income countries like India. Most of our patients survive on either child support grants or the old age grants of the grannies who look after the children. Many young girls fall pregnant while in school, between grades 9 and 12. They hand over the children to their mothers and must return to school. Some young mothers have to work. They do not get jobs in our province because it is poorly industrialised. The official unemployment rate in the country is 33%. However, the unofficial unemployment rate is about 44%, and the unemployment rate in our province for the productive age is 52%. So young people from our province go north to Gauteng Province or Cape Town in the Western Cape. Most of the children are looked after by grannies. Most of these grannies are surviving on the old age and child support grants they get for every child.”
Drs Lazarus and Chitnis started working at the Cecilia Makiwane Hospital in the township of Mdantsane, about 25 kilometres from the city’s centre, on the 1st of February 1995. Dr Lazarus got permission for them to work at the Frere Hospital in the town (East London) from 1st March 1995. “My ex-boss wanted to establish a regional paediatric surgery service”, and so he wanted the same department between the two hospitals in one city to provide better collaborative care instead of infighting between the two different departments like in the other major cities in the country, which he describes as bad for both patient care and training.
Fig 6: The logo of the Department of Paediatric Surgery in East London
“Ours is one department between the two hospitals situated 25 km apart. I am the team’s current captain, and we work at both hospitals daily. We cover the deficiencies and use the strengths of both hospitals. We shuffle patients between them as the need arises. The government built a state-of-the-art, huge, significant, new Cecilia Makewane Hospital. It opened in September 2017; we have been there for seven years. It is spacious. We have an entire general paediatric surgery ward, so bed space is not a limiting factor at that hospital. For some context, Dr Chitnis describes how there was segregation of patients based on their skin colour at Frere Hospital during the apartheid days into two wings- B for Black people, C for Europeans, and white people. During the apartheid days, only white doctors and nurses were allowed to work on the C side of Frere Hospital, where they nursed only White and European patients.
But at the Frere hospital in town, we are still on the previous black side of the hospital. Our wards have not been renovated or expanded in the past 30 years. We have only six beds at Frere Hospital in the Paediatric Surgery ward, but at Cecilia Makiwane Hospital, we have 20 beds.”
And next:
The story of Dr. Chitnis continues next week. To contact him, click here for his InterSurgeon profile.
