In Conversation with Dr. Shekhar Bhojraj

Dr. Shekhar Bhojraj is one of India’s foremost spine surgeons and a pioneer in the field of spinal care. As a former Head of Orthopaedics at KEM Hospital and a senior consultant at Breach Candy Hospital and Lilavati Hospital, he has mentored generations of surgeons and has been instrumental in advancing spinal treatment and education in the country. Recognising the urgent need to make high-quality spinal care accessible to all, Dr. Bhojraj founded The Spine Foundation in 1998, a unique initiative dedicated to bringing advanced spine treatment to underprivileged communities across India. Through free rural spine camps, research and training programmes, The Spine Foundation has reached thousands of patients who would otherwise have had no access to such expertise. Dr. Bhojraj’s vision combines cutting-edge medicine with a profound sense of social responsibility, making him not only a leader in his field but also a true humanitarian. VH: WHAT INSPIRED YOU TO SPECIALISE IN SPINE SURGERY? When I was in medical school at KEM Hospital in the mid-1970s, I developed a strong liking for orthopaedics. My father was an anaesthetist, so I was inclined towards that path. Over time, I found myself drawn to surgery, and we had excellent teachers in orthopaedics who greatly influenced me. At that time, orthopaedics mainly dealt with injuries and trauma – there were no joint replacements or arthroscopies yet. Spine surgery was a small but distinct area, and I was fortunate to train under senior teachers like Dr. Bhansali, who was a pioneer in the field. Since spine was not a recognised speciality in India in the early 1980s, I went to the UK for 5 months to train with different spine surgeons. When I returned, I established the first dedicated spine unit in the country at KEM Hospital in 1988. That was the beginning of a lifelong journey with the spine. I spent 18 years at KEM Hospital, from a medical student to heading the spine unit. Then, in 1993, I joined Hinduja Hospital to start the first specialised spine unit in the private sector. The Hinduja group supported me wholeheartedly, and that experience helped me grow as a spine surgeon in the corporate medical world. Around the same time, I was also part of the founding group of the Association of Spine Surgeons of India and served as its Secretary and President. YOU HAVE SEEN THE FIELD EVOLVE OVER DECADES. WHAT SHIFTS HAVE YOU WITNESSED IN HOW SPINE DISORDERS AND REHABILITATION ARE APPROACHED IN INDIA? The biggest realisation is that 80% of spine problems do not require surgery. They only need proper counselling, posture correction, simple medication or physiotherapy. About 20% are what we call the red flag, requiring evaluation, and of those, only 10% actually need surgery. Barely half of them agree to it, so if I see 100 patients, I may operate on only 5. That means 95% of patients need conservative care and rehabilitation, not surgery. Unfortunately, many young doctors today are very eager to operate, leading to unnecessary interventions and avoidable disabilities. I am now giving a talk titled ‘Give Instability a Chance’, encouraging surgeons to pause before cutting and to point out that though the influx of technology is important, it needs to be used sparingly and with good judgement. IN YOUR EXPERIENCE, WHAT ARE THE GAPS IN REHABILITATION FOR PEOPLE WITH SPINAL INJURIES? I am very happy that the government has looked at Ayush, where they are trying to integrate Ayurveda and Homeopathy. We take rehab teams, giving physio, also when it comes to medication, we are trying to see if we can adopt Ayurveda and Homeopathy, which is nature-based and more compatible to the poor people and much more affordable, and which they have been using for long. We are doing a controlled research study in two of our centres, in Uttaranchal and interior Karnataka on Ayurveda and Allopathy for non-operative patients. These community-based, affordable interventions make far more sense for people who cannot access or afford advanced hospital care. FROM YOUR PERSPECTIVE, WHAT ROLE CAN MEDICAL PROFESSIONALS PLAY IN PROMOTING INCLUSION AND DIGNITY FOR PERSONS WITH DISABILITIES? Earlier, the focus in health care, even in government policies, was on communicable diseases, like malaria or tuberculosis. However, now, we have good programmes and these are coming under control, and it is the non-communicable diseases such as diabetes, hypertension, stroke, congenital disorders, musculoskeletal problems and especially spinal issues that we need to focus on. These can create lifelong disability. A spinal injury does not just affect the individual – it disrupts the family, education and income. For instance, if a daily-wage farmer has a back problem and is in bed for 2 weeks, his entire family is affected. If there is a major spine problem, his children will drop out of school and his daughter will not get married. This is known as catastrophic health expenditure. Hence, health care must go beyond curing disease; it must focus on restoring function and dignity and ensuring people can live independent, meaningful lives despite their disability. DO YOU THINK AWARENESS ABOUT SPINE HEALTH AND RELATED DISABILITIES IS ADEQUATE IN INDIA? WHAT MORE NEEDS TO BE DONE? The metros have good facilities; however, 70%–80% of the people live in the rural areas where there is no access to health care. I do not think the awareness programmes are adequate in the interiors. We realise that awareness is very important and prevention is very important because they cannot afford to be out of work. This is one of the important functions of The Spine Foundation. We train ASHA workers and community volunteers to spread the awareness. We have also started physiotherapy assistant programmes for young people in villages who may not have completed school so patients can avoid surgery. We are also starting a preventive programme with the National Institute of Occupational Health, where they have devices to prevent spine problems in villages. There is also an Ayurveda project that we are looking at. WHAT RECENT ADVANCEMENTS IN SPINE SURGERY OR TREATMENT EXCITE YOU THE MOST? Each and every advance in spine surgery is very exciting, because for the 5%–10% who truly need surgery, we must offer the best, and each innovation is helping us do that. Minimally invasive spine surgery has been a boon for both a person in a metro and a villager, who can get back to work in 2 days. We are trying to introduce minimally invasive techniques in our Kolhapur rural unit and studying how to lower costs and help patients return to work faster. We are using artificial intelligence (AI) in outreach programmes and in generating awareness. We conducted a study using AI-based questionnaires among the urban poor in Bandra’s slums. We evaluated them free through The Spine Foundation. We are presenting these results at a national conference soon. HOW DO YOU VIEW THE BALANCE BETWEEN CUTTING-EDGE TECHNOLOGY AND ACCESSIBLE, AFFORDABLE HEALTH CARE FOR THE MAJORITY OF PATIENTS IN INDIA? Our philosophy is clear: only 5% need surgery. For them, cost is never a barrier. We do not compromise and use the best technology available. The Spine Foundation ensures that even a poor farmer’s daughter gets the same standard of care as anyone else. For example, if a child in Assam or a farmer’s daughter in rural India needs complex surgery, we fly our equipment and team there. We do not compromise on quality. The surgery we do in the village is no different than what we do in Breach Candy. We are restrictive in who comes into the Foundation. We have a very active and structured 2-year Fellowship Programme so whoever joins us becomes a Brand Ambassador for our philosophy as well as contributes to our Camps. We now have close to 300 young medical students who are a part of us, who are tuned to the social aspect. HOW HAS WORKING WITH PATIENTS WHO FACE LIFELONG CHALLENGES SHAPED yOUR OWN OUTLOOK ON RESILIENCE AND HUMAN SPIRIT? Eighteen years at KEM Hospital and a family background rooted in Gandhian values have shaped my perspective. My grandfather was jailed with Sardar Patel, and my father came from Vidarbha on a scholarship. We have been in this mode since the beginning. When other colleagues were in practice, the Foundation gave us enormous opportunities to intermingle and stay connected to people at the grassroots. We use the same principles in the city. We now have a team of 50 spine surgeons all over the country, and soon, we will have 100, and that is how we will spread the philosophy. IS THERE A PARTICULAR PATIENT STORY THAT HAS STAYED WITH YOU AND INFLUENCED YOUR PRACTICE OR PHILOSOPHY? Two stories, actually. The first is from Nandurbar, a tribal district. It is on the border of Maharashtra, Gujarat and Madhya Pradesh, so it gets neglected by all three governments. A young girl fell from a tree, became paraplegic and lay untreated for a month because there was not even a primary healthcare centre nearby. She lay incontinent for a month, with bed sores and infection, as her parents did not know where to go. Plus, they were daily-wage earners, so taking time off would mean they would starve. An NGO got to know and arranged for her to come to St. George Hospital in Mumbai and publicised the case. The then Health Minister visited and realised the complete lack of healthcare there. That led The Spine Foundation to adopt the Nandurbar Civil Hospital, which today is one of our biggest centres and has a functioning medical college. The second story is of a schoolteacher’s daughter from Arunachal Pradesh with a severe spinal deformity who was losing her ability to breathe. Her mother took a government loan and travelled for 2 days to reach Mumbai. We operated on her free of cost. She recovered completely, grew four inches taller, became a schoolteacher herself and got married. She gifted me a traditional shawl, which I treasure. WHAT MESSAGE WOULD YOU LIKE TO GIVE YOUNG DOCTORS, RESEARCHERS AND REHABILITATION PROFESSIONALS ENTERING THE FIELD TODAY? Spine surgery is a very important branch. At The Spine Foundation, we welcome young professionals through our volunteer programmes. There are many who are not part of the Foundation, but come for our camps. I encourage young doctors to remember the 80-20-10-5 rule. Not everyone needs surgery. Adopt new techniques, keep your feet on the ground. Treat not just the top but the bottom of the pyramid as well and include all other aspects of spine care along with surgery.