Two years ago, 22-year-old Hvovi Minocherhomji had just had a celebratory meal with her parents to mark the end of her B Com exams. Soon after that she dropped to the pavement and almost died. Her heart had stopped beating.Hvovi was rushed to a local hospital, Holy Family, where she was revived. She was later told that she was a prime candidate for a heart transplant.
"This was the first time we were told that transplant was an option," says her father, Ascy, 62, a retired captain in the merchant navy.
Hvovi had been diagnosed with cardiomyopathy, a disease of the heart muscle, four years earlier. "On the day that she collapsed, the defibrillator that was placed on her chest to shock the heart back into action in case of cardiac arrest didn't work," says Dr Brian Pinto, chief of cardiology at Holy Family. "She should have been told to get a heart transplant years ago, since hers was such a severe case."
Discussing the option of a transplant, Dr Pinto recommended a doctor in Chennai.
"It never occurred to me to recommend a Mumbai hospital, since they haven't had a successful procedure yet," he says.
The young woman had the transplant last June, in Chennai, and celebrated by going to the US and riding rollercoasters.
"Before the transplant, I couldn't walk from my bedroom to the dining room without getting breathless," she says. She is now completing a course in Chennai at the Mohan Foundation, an NGO that coordinates organ donations, where she is studying organ donation, coordination and its surrounding legalities.
"The doctors I had in Mumbai before Dr Pinto were wonderful," says Minocherhomji. "But they did not tell me that transplant was an option. I want to come back to Mumbai and make people aware of this procedure."
Hospitals in the city admit that they often do not recommend a transplant because there is no credible centre in the city to refer them to.
"We see at least five or six candidates a month who would be ideal for a heart transplant," says Dr Charan Lanjewar, a consultant at the department of interventional cardiology at KEM, the city's largest government-run hospital. "Since KEM provides tertiary care, we get a high number of end-stage heart failure patients. But as there is no cardiac transplant unit here, we stop the treatment at prescribing drugs."
At most, Lanjewar adds, the hospital refers candidates to Chennai and Delhi hospitals.
"People are not getting heart transplants in Mumbai because there have been no heart transplants in Mumbai, thus making it a sort of self-fulfilling prophecy. We need to get the ball rolling," says Dr Ramakanta Panda, a cardiovascular thoracic surgeon and vice-president at Mumbai's premier Asian Heart Institute.
Successful heart transplants are a growing phenomenon in the country. While there were only 70 transplants in all in the 17 years between 1994 and 2011, 2014 saw Chennai alone conduct 35 successful procedures, up from 16 transplants each in 2012 and 2013.
Meanwhile, hospitals in Coimbatore, Bengaluru, Hyderabad, and Chandigarh conducted six, five, one and one heart transplants respectively, in 2014.
Delhi, on the other hand, conducted just two successful heart transplants in 2014 - not a very healthy number for a city with such massive health infrastructure.
In all, the capital has seen just 34 transplants since the first such procedure in the country was conducted at the All India Institute of Medical Sciences (AIIMS), on August 3, 1994.
Mumbai is not even part of this trend, despite Maharashtra having the second-highest number of heart donations in the country - 52 in 2014, preceded only by Tamil Nadu, which had 136. This is a decade after the first Mumbai hospital was granted the status of a heart transplant centre.
With little hope of a transplant in the city, there were only two names on the waiting list from January 2014 to May 2015.
There are no names on the list any more. Both patients died over the past two months, of cardiac arrest. One was a six-year-old boy, Hammad Sayyed; the other a 40-year-old housewife from Borivli.
"With such a small pool of recipients, the chances of finding a match plummet, so we have never even had a case get to the operation stage," says Dr Panda. "We've had a couple of false starts, where in each case there was a problem with the donor organ and the surgery could not go forward."So why has the ball not got rolling yet in Mumbai and Delhi, cities of super-speciality hospitals, state-of-the-art procedures and growing medical tourism?
"There is a difference in the way the medical community in Chennai, and the one in Mumbai works," says Dr Vijay Agarwal, chief of paediatric cardiology at Fortis, Mumbai. "In Chennai, the focus is on making hospitals centres of excellence. Here, the commercial bottom line often takes precedence. Transplant units are expensive and time-consuming projects. For many hospitals, it's just not worth it to pursue."
Dr Panda adds that a heart transplant is, comparatively speaking, an easy medical procedure. "It's the ecosystem around it which Mumbai has had trouble in fostering. There are so many factors - organ availability, coordination between doctors, patients and transplant agencies, logistical support and expertise - which need to come together for a success."
In Delhi too, there have been problems creating the right environment.
"A heart has to be transplanted within four to six hours of the donor being declared brain-dead, which makes the work of the Organ Retrieval and Banking Organisation [ORBO] critical," says Dr Balram Airan, who heads the heart transplantation team at AIIMS.
HITS AND MISSES
"Chennai has seen a stratospheric growth in transplants because of the support of the state government, and because of the many dedicated doctors working here," says Dr KR Balakrishnan, director of cardiac sciences at Fortis, Malar in Chennai.
Dr KM Cherian conducted Tamil Nadu's first such procedure, in 1995, and has since done 50 more. "Seeing a number of successful heart transplants, and seeing how transformative they can be, has spurred us on," says Dr Balakrishnan.
This has meant that, over the years, Chennai has fine-tuned the crucial logistics involved in any successful heart transplant, to include a wide network of hospitals, three transplant registries, the traffic police and even airport authorities when necessary.
With support from the Tamil Nadu government, educational and training programmes on transplantation are conducted by doctors to spread awareness.
"Chennai's doctors have pushed through bureaucratic red tape and cajoled officials into helping with coordination," says Dr Sunil Shroff, convenor of the Indian Transplant Registry, a national body run by doctors to facilitate transplants. "This is the key reason that the procedure is conducted as often and as successfully as it is in this city."
It is precisely this kind of coordination that is missing in Mumbai and Delhi.
"Maharashtra has consistently had a high number of cadaver donations over the last three years," says Shroff. "All 52 hearts donated here in 2014 went to waste because of a lack of facilities, coordination and awareness."
The problem starts, says Shroff, between the patient and the doctor who should be referring them to a cardiac surgeon. "The awareness about this option has huge gaps," he says.
In Delhi, three weeks ago, three hearts were donated over three days. One was transplanted; the other medically unfit. Matching recipients could not reach Delhi in time for the third.
Take the case of Rahul Thakur. In March, the 21-year-old from Maharashtra's Jalgaon district became the first person in the state to undergo a heart and lung transplant - in Chennai. He only found out that transplant was an option, he says, when he read about Hvovi in the newspapers. "We made repeated trips to Mumbai, but were never referred to transplant units. We were told by doctors in Mumbai that a transplant would only be possible in the US," says his uncle, Tushar Kapoor, 40, a Jalgaon-based mobile shop owner.
"We contacted an American hospital, where there was a waiting period of three years." Kapoor says that among others, the family consulted with Dr Suresh Rao, a pediatric cardiologist at Kokilaben Dhirubhai Ambani Hospital.
Rao says he has no memory of seeing Thakur. "The name doesn't register," he says. "I see a lot of children in similar circumstances."
The family read of Hvovi's transplant in the newspapers last year, and began contacting doctors in Chennai. "I just wish I had known earlier," says Thakur. "I had a hole in my heart since I was born. I had to drop out of school at the age of 12 because I kept collapsing. Now, I can read, I can go for walks with my family, I can help in the kitchen. I can even play cricket with my friends."