Public Health: Chennai

Poverty amidst plenty

Print edition : April 14, 2017

Patients in the orthopaedic ward of Stanley Hospital in Chennai use their own table fans. A 2013 photograph. Photo: B. Jothi Ramalingam

Chennai has a surfeit of medical facilities, but access to health care for the poor and needy remains an issue.

THE Chennai metropolitan area, spread over 1,189 square kilometres in three districts and home to a seventh of the population of Tamil Nadu, has the best concentration of medical facilities anywhere in the country. From primary care to doctors’ availability to superspeciality infrastructure, Chennai has it all. But this was no accident.

Madras Medical College (MMC) was inaugurated on February 3, 1835. Eye Hospital, Egmore, attached to MMC and the second of its kind in the world, was started in 1819. MMC is also the first medical college in the world to admit a female student, Mary Ann Dacomb Scharlieb, in 1878. Soon after she passed out, she started Kasturba Gandhi Hospital (KGH, earlier Gosha Hospital) in Triplicane in 1885. The first Indian woman to graduate from MMC, Muthulakshmi Reddy, set up the Adyar Cancer Institute in 1954. Of the 32 districts in Tamil Nadu, 17 have government medical colleges—21 colleges in all (22 if the ESI College is included). Again, Chennai and its neighbourhood have the maximum number of such colleges: apart from MMC, Stanley Medical College, Kilpauk Medical College, Government Medical College (Omandurar Government Estate), Chengalpattu Medical College, and ESI-PGIMSR in K.K. Nagar. In addition, there are 19 private medical colleges. According to the Medical Council of India website, 13 of these are in Chennai or the two adjoining districts.

On paper, Chennai has a surfeit of medical facilities, but access to them for the poor and needy still remains an issue. Private medical institutions have to set apart 10 per cent of their bed strength to treat poor patients. But a top medical administrator confessed that he was unaware as to how many of the hospitals followed this in practice. The State government did not push for strict adherence to this principle, and many private institutions which have received government support in one form or the other get away with little oversight.

The Chennai Corporation is the focal authority for the delivery of health services and maintenance of public health in 426 square km of the Chennai metropolitan area. The urban local bodies in the area outlying the corporation, monitored and staffed by the Public Health Directorate, form the nodal agencies for health-related issues in their respective localities.

A clear demarcation of responsibilities in the area of education, delivery of services and monitoring of public health, strengthened by consolidated legislation, forms the basis of Tamil Nadu’s approach. The efficacy of the system has been tested in critical situations. During the outbreak of cholera in Chennai in 1992-93, which was caused by a virulent, new form of bacteria, O-139 (later named Bengal strain), the government ordered chlorination of water 100 times over the permissible limits, for more than three months. The epidemic was contained. Two decades later, when a dengue outbreak claimed over a 100 lives in the southern tip of Tamil Nadu, in Kanyakumari and Tirunelveli districts, the administration, which woke up late to the challenge, managed to limit the damage with drastic, emergency measures.

In 2017, even as some sections of the population made it clear that they would not allow their children to be vaccinated against rubella and measles, the Health Minister asserted that parents had no choice in the matter. These three examples prove that when it comes to a public health emergency, the Tamil Nadu government had acted decisively.

Health officials here credit the system in place for much of the things that have gone right so far. The World Bank is on record, in 2006, appreciating the work of the Tamil Nadu government’s Health Department after the 2004 tsunami.

Bursting at the seams

Despite these positives, the health delivery system is bursting at the seams. The department has a staff of over a lakh, serving an average of six lakh outpatients a day. The inpatient capacity is 82,000. Impressive statistics, but the fact remains that just over a 100 doctors are available to examine 25,000 patients who walk into a public hospital in Chennai between 7 a.m. and 11 a.m. (the outpatient duty hours) each day. Recruitment to the health services is not a continuous process, and there is usually undue delay in filling up vacancies. Besides, the number of posts has not kept pace with the population growth.

Malaria, filariasis, dengue and cholera are endemic in Chennai. The outbreak of these diseases appear to be cyclical. Malaria is by far the biggest problem in Chennai. Health Department statistics show a sharp downward trend in the cases of reported malaria cases in the city—from 51,272 cases in 1990 to 2,707 in 2016. Medical practitioners across the State are supposed to report any cases of communicable diseases they come across while examining patients. In practice, this hardly happens. A few private medical practitioners claimed that the process was cumbersome and hence discouraged reporting, while Health Department officials said that this was not the case.

In the case of tuberculosis, one in every 100 men in Chennai aged between 55 and 64 has infectious pulmonary tuberculosis, five times higher than the incidence among women, The Times of India reported on May 7, 2015. “What is more alarming is that a majority of these cases escape detection, the first urban-based TB prevalence survey in the country has revealed. The study undertaken by the National Institute for Research in Tuberculosis was published in a peer review journal PLOS ONE,” the report added. An additional worry is the emergence of drug resistant TB.

The lifestyle diseases map in Chennai is alarming too. Of the roughly 45,000 deaths in Chennai area annually, 28,000 are on account of cardiac and vascular-related complaints. This correlated well with the National Family Health Survey-4. According to key indicators put out by the NFHS-4 (2015-16), nearly a third of women in Chennai are overweight (33.6 per cent; men 31.3 per cent), and as many as 53.9 per cent in the 15-49 age group are anaemic. Another key input is that though government hospitals offer almost everything free for poor patients, the average out-of-pocket expenditure per delivery in public health facilities is Rs.1,818 (about Rs.500 less than the State average). Cancer detection rates are showing an upwards trend, according to doctors, but dedicated facilities available for treatment are very few: Adyar Cancer Hospital, Apollo Speciality and the much smaller Rai Memorial. The mental health sector faces a similar situation with the dedicated Institute of Mental Health remaining poorly staffed. Despite non-governmental organisations such as The Banyan and SCARF working for the mentally ill, the gap remains significant.

On the whole, despite being called the “Mecca of Health Care” in India, Chennai falls short of adequate health care facilities for the common people.

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