Posts Tagged ‘cleanliness’

Himalayan Blunders in Healthcare – Gorakhpur and Beyond

This article was originally published on Indus Dictum, a site where thought leaders from diverse fields, spanning business and technology to politics and modern law, contribute unique insights and experiences. You can access the article at https://indusdictum.com/2017/08/17/himalayan-blunders-in-healthcare-gorakhpur-and-beyond/

In a country which is seemingly inured to bad news, the news of the deaths of a large number of children, infants and adults in a major hospital in Gorakhpur, Uttar Pradesh (UP) was like an atom bomb being dropped. Predictably, the blame game started immediately, with every opposition party and every media hack trying to pin the blame on someone, preferably the head honcho of the state. The previous Chief Minister was loudest in his criticism, forgetting that he had presided over the destinies of the state (and its health systems) till just a few months ago. In this atmosphere of cynicism and one upmanship, we are in danger of losing sight of the disease and focusing merely on the symptoms.

Let us start with some visuals, which convey the bald facts about the state of amenities in the Paediatric and Neonatal Intensive Care Units (PICU and NICU) of the hospital in question, the Baba Raghav Das (B.R.D.) Medical College and Hospital, the major tertiary health facility in the city of Gorakhpur, the bastion of the present Chief Minister of UP. These are reproduced from a tweet from Rahul Verma (@rahulverma08) based on the replies to a Right To Information (RTI) query of 2011.


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Reply from the office of the Principal, B.R.D. Medical College, to an RTI application.


The RTI reply of early 2012 gives telling evidence about the lack of facilities in the hospital (in particular, the non-functioning of critical life-saving equipment because of poor maintenance) and the significant staff shortages in both medical and nursing staff. Although this is a slightly dated reply, there is little reason to suppose that matters have greatly improved in 2017, given the disclosure that lack of oxygen supply to children and neonates could possibly have been a prime cause of the large number of deaths.


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Staffing shortages in medical and nursing personnel (Jan 2012)


The reply, which is signed by the Head of the Department of Paediatrics of the hospital, shows that 50% of the qualified medical posts are unmanned and 40% of the nursing posts are not filled in. Even more disheartening is the state of affairs in respect of critical equipment in the ICUs. The incubators, pulse oximeters and infant ventilators are not working, while 16% of the cardiorespiratory monitors are non-functional.

Only a detailed enquiry will (hopefully) establish the truth of the allegation that one of the primary causes for the deaths was, apart from encephalitis, the shortage of oxygen supply in the paediatric and neonatal wards. I am not too sanguine about the truth in this regard coming out given the conflicting statements from politicians, doctors and bureaucrats on when payments were released to the oxygen supplier and on whether oxygen shortage was in fact responsible for the deaths.


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Status of equipment and machinery in PICU and NICU.


But the issue goes far deeper than that of lack of oxygen supply alone. It is a pointer to the systemic rot in UP’s public institutions and in its systems of governance, a malaise that can be seen across institutional structures in different Indian states. Nowhere is this better exemplified than in the condition of India’s health systems.

UP’s public health care systems do not reach many of its citizens, especially the most vulnerable. This is partly due to the low percentage of public expenditure on health systems, as reflected in a 33% to 40% shortfall of over 31,000 health sub-centres, over 5000 primary health centres and 1300 community health centres in the state (as reported in the Financial Express). On top of this is the abysmal functioning of even such public health care institutions as do exist at the primary and secondary levels and the resultant lack of confidence of the public in these facilities. With primary and secondary public healthcare services not adequately available in Gorakhpur and its neighbouring districts, Sant Kabir NagarSiddharth NagarMaharajganjKushinagar and Deoria, the public is forced to come to a tertiary care facility even for ailments that can be treated at lower levels. A large hospital that already suffers from shortage of funds and skilled manpower, poor management, and corruption, is thereby further overburdened. The National Family Health Survey of 2015 (NFHS-4) data reveals the poor quality of health services that mothers and children receive. While 5% to 10% of mothers receive full antenatal care, medical check-up of neonates in the first two days after birth ranges from 9% to 25%. About 66% of children in the 12-23 month age group are fully immunised in Gorakhpur and Deoria districts, with the percentage falling to just over 40% in the other four districts.

Not surprisingly, then, rates of child undernutrition, morbidity and mortality, as well as maternal mortality rates (MMR), are high in this region. Mortality rates of under-5 children vary from 76 to 116 per 1000 live births and of infants (0-1 year) from 62 to 87 per 1000 live births, with 80% of the infant mortality rate being accounted for in the first 28 days after birth. Stunting and underweight rates in under-5 children exceed 40% and 32%, with well over 10% of children falling in the wasting category. MMR in the Basti and Gorakhpur mandals, where these districts are located are 304 and 302 respectively per 100,000 live births (all mortality figures are taken from the Annual Health Survey 2012-13 of Uttar Pradesh, conducted by the Census Commissioner of India and undernutrition figures from the NFHS-4 data). All these figures are distressingly high and place many of UP’s districts in the same league as war-torn states of Africa in health and nutrition indicators.


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The underlying morbidity and mortality proneness of the population in this region, especially its children, is exacerbated by the surrounding external environment. In their recently published book, Where India Goes: Abandoned Toilets, Stunted Development and the Costs of Caste, Diane Coffey and Dean Spears have highlighted the contribution of the practice of open defecation to high stunting rates in children. Open defecation has persisted despite the Swachh Bharat Abhiyan, because of the notions of pollution associated with latrines in the house and the reluctance to empty the pit latrines. The Japanese Encephalitis (JE) virus, to which a large number of the present deaths are attributed, is spread by the Culex mosquito breeding in the swampy paddy fields which are a feature of eastern UP. With traditional immunisation rates themselves being low in this region, it should be self-evident that the two doses of the JE virus immunisation are also not covering a significant portion of children. Insanitary conditions coupled with poor immunisation rates and failure to reach health care early to affected persons – especially children – constitute a lethal combination that contributes significantly to high mortality rates.

This deadly cocktail of factors is aggravated by the endemic corruption in the health and nutrition sectors in UP. The scam in the National Rural Health Mission in UP has been facilitated by politicians and highly placed bureaucrats, including some from my former service, the IAS. Fictitious purchases of medicines for which payments were made were facilitated by doctors and officers of the health department in collusion with suppliers. This disease is by no means confined to UP: nearly every state in India is prone to this syndrome, given the centralisation of purchase powers in the state secretariats. In fact, the purchase of medicines is mostly made keeping in mind the interests of politically-linked powerful suppliers, with no analysis of the disease and illness pattern in different areas of the state, which would enable a scientific assessment of the type and quantum of medical supplies required. States are loath to adopt the pattern of Tamil Nadu, which set up the Tamil Nadu Medical Services Corporation over two decades ago to streamline the procedure for procurement, storage and distribution of essential drugs and medicines to government medical institutions throughout the state. UP has a similar scam operating in the ICDS sector, which is meant to provide wholesome take home rations to mothers and under-3 children, and hot cooked meals to children in the 3-6 year age bracket. A recent LANSA study details the systematic misappropriation of huge sums from the ICDS budget for lining the pockets of the politician-bureaucrat-contractor nexus.

Once again, in the ritual breast-beating that is going on in the media, there is the real danger that we will revert to the “business as usual” approach after a short hiatus. The Harvard economist, Lant Pritchett, characterised India as a “flailing state”, not quite failed like many of its Asian and African confrères but where accountability is extremely weak and where there is little control of the head over the limbs of the state. Even this is a very charitable interpretation given that, in the Indian context, the limbs behave just as the head dictates. What I wish to highlight is the need to focus on systemic processes and institutions rather than personalities and political formations. As the preceding paragraphs seek to establish, a combination of factors – man-made and natural – have contributed to the ongoing crisis in India’s health systems. Rather than looking for temporary scapegoats, the need for an overhaul of the system is overdue (one possible solution is outlined by the Foundation for Democratic Reforms). The acid test for the new government in Uttar Pradesh has arrived, whether it will tread the same beaten track of its predecessors or chart a new path to governance and the arrival of achhe din in UP. Else, we will be left to exclaim “Even you, Brutus?”

Swachh Bharat or Swachh Bharatiyas?

As another Independence Day rolls along, we, as Indians, need to introspect on an issue that we are all fond of speaking and writing about but not so much on taking positive action. The Father of the Nation, Mahatma Gandhi, with his eye for detail and his passionate conviction about the need for self-improvement, deplored the insanitary habits of his countrymen. It is, therefore, in the fitness of things that his 145th birth anniversary in 2014 saw the launch of the Swachh Bharat Mission by the Indian Prime Minister. And yet, if one sees the habits of fellow Indians, one doubts whether the ambitious goals to be reached by the Mahatma’s 150th birthday will be realised. I do not wish for a moment to spread pessimism about what is undoubtedly a noble venture. It is just that our countrymen (and, to a lesser extent, countrywomen) are still so blissfully ignorant of, or uncaring about, basic hygiene. The four letter words that we are taught to abjure in conversation are very much in existence when we undertake, in public, different functions relating to waste disposal (for the sake of politeness, I will leave it to my readers to infer them).

The first and foremost sight that assails our visual senses whichever way we turn is the one huge garbage dump we have made of our habitations, whether city, town or village. I had personal experience of this till recently at the flat in Bengaluru where I stayed for one year. The open space next to the flat was the dumping ground for the solid and liquid waste of all the households in the area. The owners/tenants of the higher floors of flats abutting the open space did not even take the trouble of coming down to throw the waste; the law of gravity did all their work. Compounding the problem in Bengaluru is the absurd approach of the Municipal Corporation, which apparently does not believe in garbage bins. Not surprisingly, there are piles of garbage at every street corner, adding to the menace of flies and mosquitoes. Bengaluru may be the information technology capital of India, but it is also fast achieving the status of the dengue capital of India. Even when the garbage is collected, no scientific method of segregation of wet and dry waste is employed; the entire muck is thrown into the back of three-wheeler vehicles. I am told that the transport lobby is powerful enough to stall alternative approaches to waste collection. While working in the Mumbai Municipal Corporation in the late 1990s, one of my jobs was to oversee the cleaning of storm water drains in the eastern suburbs from Chembur to Mulund. With every type of dry and wet waste finding its way into these drains, including industrial scrap from the thousands of small manufactories in Kurla, it came as no surprise that the first heavy downpour accompanied by high tide levels would leave large parts of the city totally submerged. The same story repeats itself even today in Mumbai, despite the (pious?) intentions of the city fathers (and mothers) and its bureaucrats. In the late 1990s, Mumbai had created a force of nuisance detectors empowered to detect and penalise (through fines) citizens littering and spitting on the roads. Like all good ideas, this died a natural death in the course of time. But, in the final analysis, it is only when his pocket is hurt that the blasé Indian citizen will heed instructions on waste disposal, as he does in Singapore, San Francisco and Sydney.  Nor is the problem of waste limited to land sites. The cleaning of the holy Ganga River, revered by millions of Indians, was undertaken with much fanfare almost thirty years ago. There is little to show for all the money, time and effort that have gone into this exercise. Contrast this with the successful exercise in fifteen years after 1986, of the Swiss, French and German governments, to improve the quality of water in the Rhine River, which flows through heavily industrialised areas. Water quality monitoring is carried out every six minutes at different points along the river in Germany and offending industries are penalised. One has not heard of any similar measures being implemented along the Ganga, with the tanneries of Kanpur City spewing out carcinogenic poisons into the river, not to mention the many urban settlements along the course of the river discharging their sewage directly into the Ganga.

We move on to another national pastime: spitting. An apocryphal story has it that Mahatma Gandhi once remarked that if all Indians spat together, it would be enough to drown all the three hundred thousand Englishmen ruling India. The habit shows no signs of abating after India’s independence. Move anywhere in public and you are greeted by a hoarse, hawking sound, followed an instant later by the expectoration of an ample quantity of body fluid. The widespread fondness for betel leaf (paan) and tobacco lends a touch of colour to the environment. The walls of public buildings (especially staircases) receive a generous coat of human paint at regular intervals. Woe betide the individual dressed in spotless white clothes: he has a more than even chance of getting his clothes dyed a reddish pink through the oral efforts of his fellow man (yes, this is an activity to which gender equality has not yet percolated). And yet this is one activity where no concerted public action is evident till today, notwithstanding its public health hazard: the prevalence of tuberculosis in India is, at least in part, an unfortunate consequence.

There is yet another waste disposal activity which has remained a jealously guarded male preserve: urinating in public open spaces and on walls of buildings. Build any number of public toilets and Sulabh Shauchalayas: the male Indian still retains his birthright to let fly in public. I still remember being overcome by ammonia fumes when passing one of the colourful gates in Jaipur; architectural marvels are not immune to these depredations either.

And then we come to India’s greatest public health and sanitation problem: open defecation. Not only is this a major cause for the spread of an assortment of communicable diseases, recent studies have also established a direct correlation between this and child stunting, where India registers one of the highest percentages in the world. Women bear the brunt of the lack of toilets: not only does it constitute an affront to their dignity, it also compromises their safety when they have to venture forth in darkness. I still recall the women of the village having to hastily stand up on the roadside in the midst of their ablutions in fading daylight when, as a district officer, I had to enter or leave the village at that hour. Toilets in urban slums were, and still are, badly maintained and child-unfriendly, leading to highly insanitary conditions in areas already burdened by poverty and poor healthcare access. Even after fifteen years of a national sanitation campaign, more than half the country is not served by toilets, whether public or private.

I have not even touched upon noise pollution, an area where India, with its election campaigns and religious functions, not to mention car, bus and truck horns, holds its head proudly aloft in the comity of nations. A touch of black humour has been injected by a recent Indian government report ranking the best performing Indian cities in the Swachh Bharat campaign. Bengaluru, which I have had occasion to refer to earlier, ranks among the ten best cities in the country. Experts feel this high ranking is largely on account of good intentions and the relatively worse position in other cities. It reminds me of the finance manager-philosopher Nicholas Taleb’s description of Mediocristan where the values of a population are clustered around an average in what we term to be a normal distribution. In the Indian Mediocristan, a slightly better performer tends to be eulogised since the benchmarking is by modest national rather than outstanding international standards. Be that as it may, it is now time for all Indians to pay attention to issues that bedevil not only our lives but imperil those of future generations as well. With apologies to Cassius, “The fault, dear Indians, is not in our stars, but in ourselves”. The Mahatma was prescient in making cleanliness one of his planks for social change; it is apt to close with a quote generally attributed to him “हम सुधरेंगे जग सुधरेगा” (be the change you want to see in the world).

 

Happy Independence Day!