The dengue patient

IN A HOSPITAL in Tiruchi. Government health facilities are short of beds, staff, equipment and more. - M. MOORTHY

Our health care system is ailing; an immediate and large infusion of public funds is required to set things right.

I SHALL call her Madhu. But her name is not really important for her experience is one that is only too common, except perhaps that it has had a better outcome than many others.

Madhu, a migrant drawn to the city to earn some money for herself and her family back in the village, works as a maid in a home in South Delhi. She was lucky: she found a place to stay with reasonable employers. When she fell ill, they paid for her to consult a series of private doctors recommended by friends and neighbours.

It was just as well that they did, because the doctors she consulted charged quite high rates, even though their clientele was typically quite poor, and insisted on a range of expensive tests - scans, X-rays and the like - before coming to any diagnosis. So in a matter of three weeks, the private medical treatment had cost Madhu several thousands of rupees.

Yet this succession of doctors was somehow unable, notwithstanding the tests and the many pills and injections that they inflicted upon poor Madhu, to deal with the actual illness, which in fact was a severe urinary infection. So Madhu was already in a weakened state when she experienced a very high fever.

This fever too was dealt with by a local private doctor in the simplest possible way - through an injection that lowered the fever without addressing the cause. Yet the latest fever, and the symptoms that accompanied it, turned out to be the result of dengue, the mosquito-borne viral disease that has assumed epidemic proportions in Delhi.

By the time this was finally diagnosed correctly, Madhu's condition was extremely serious because her blood platelet count had fallen to critical levels and she was in urgent need of hospitalisation. But even this is not straightforward in Delhi. The richest city in India in terms of per capita income has only a handful of hospitals that are equipped to carry out blood platelet transfusions, and these hospitals were already either filled to overflowing or ruinously expensive.

The two government-run hospitals with the required facilities already had more patients than beds, and one of them was reeling under its own local dengue epidemic. So at first it seemed that she could not even be admitted to a hospital despite being in this critical condition. Once again, though, Madhu was "lucky": her employers knew someone important who knew someone more important, which is how most things are managed in this city.

After some string-pulling, Madhu was finally admitted to the emergency ward of one of these government hospitals. She had to share a bed with two others in a ward bursting at the seams with three times the people it could formally hold, all in varying degrees of distress or criticality. The ward was in utter chaos, with the already basic facilities being completely overstretched, new patients arriving every few minutes and periodic crises being handled only by a small group of utterly overworked doctors and nurses. Naturally, there was little possibility of "normal" hospital procedures in such circumstances, or of individual care for any one patient.

In spite of the dreadful conditions, Madhu was treated and is now recovering, so her story is one of survival. But there were (and continue to be) many others who were less lucky: those who came in too late, those who could not even get into the hospital, those who never got diagnosed properly despite going to doctors, those who could not even afford to go to the doctors in the first place.

For all those who are currently obsessed with the emergence of India as the new kid on the block of potential economic superpowers, exposure to the conditions in most of our government hospitals should be made compulsory as an important antidote. It is immediately apparent in any of these places that the problem is not one of "poor management" as is often assumed about publicly run institutions.

On the contrary, it is really a miracle how the doctors, nurses and other staff of these hospitals manage to deal with the torrent of cases that they are exposed to on a daily basis.

The real problem in all of these places is one of complete shortage - of medical professionals, of other staff, of rooms, of beds, of equipment, of medicines, of everything. Government health facilities that were set up to cater to a few lakh citizens are now having to deal with a reference population of several million, and they are deprived of crucial facilities and adequate numbers of health workers.

So it is not surprising that the care is inadequate or that the conditions are poor; what is surprising is how, despite these truly appalling circumstances, basic health care and even more complicated care are still delivered regularly in government hospitals.

But obviously, for any improvement in these unacceptable conditions, there must be a much larger infusion of public funds to provide all the things that are now in such short supply, from physical infrastructure to human resources.

The abysmal conditions of health care in our country - both public and private - are often ignored by the elite, who have seceded into their own privileged world of five star hospitals financed through expensive medical insurance. And even among those with a stronger sense of reality, it is often assumed that the real health gap is the rural-urban one, especially since public expenditure on health disproportionately favours urban areas.

Yet the poor - and the not-so-poor - in urban India are also very badly served by this system, which lets them down on so many counts even while forcing them to pay larger shares of their own income on health care. There are public failures in terms of inadequate investment and inefficient regulation. The parlous state of and the sheer difficulty of access to government hospitals forces even the poor to turn to private practitioners.

But in private care, especially for the poor, there is a proliferation of poorly trained or even completely spurious practitioners, who somehow have to recoup the large investments they have made on their own medical education by fleecing patients. So, there is often an unholy nexus between such doctors, testing laboratories and the agents of medical firms who peddle the more expensive medicines. The more glamorous hospitals with better facilities, which are all supposed to provide some proportion of free care to the poor, have proved to be remarkably adept at evading this legal requirement. So poor people rarely, if ever, get access to them.

But even the government hospitals are hard to get into. Furthermore, they are hugely demanding of time, which is one of the most expensive things even for the poor. Outpatient visits typically require at least a half day's or even a full day's leave because of the long queues involved. In-patient care is even more demanding of the time of the patient's family.

Since government hospitals are so short-staffed, they function according to a system whereby nursing is relegated to a bare minimum. So each patient must have an attendant at all times, not only to do some of the things that nurses do in hospitals elsewhere in the world but also to inform the ward nurses of the patient's condition, to buy medicines whenever necessary, and so on.

This means that even poor families with daily wages as the main source of income will be forced to have a family member - typically an earning member - spend the entire time at the hospital with the patient.

Usually, there is next to no provision for the needs of the attendant, who will have to sleep on the floor of the general ward and find food and other necessities somehow. The sight of patients' attendants and families stretched out on the floor of hospital corridors, with their hampers of food and basic clothing, is now so common for us that we barely notice it. But it would be unthinkable in most parts of the world, including in most of Asia.

Somewhere we have lost our bearings as a society since we allow this appalling health care system to continue and even get worse. If we do not address this most basic of social issues, the chances are dim of us getting anything else right.