Chief Minister in hospital

AN ambulance pulled up at the entry to the emergency room (ER) of the Apollo Hospitals on Greams Road in Chennai on September 22 around 8:45 p.m. The ER responders wheeled the patient, Tamil Nadu Chief Minister Jayalalithaa, into the facility. She was unconscious and had to be resuscitated, said two sources, independent of one another. With her in the ambulance was her trusted aide, Sasikala. Her secretary for all practical purposes, Poongundran, who followed in a vehicle behind, was at the ER.

There was some surprise as the patient was wheeled in. This was because the first call from Veda Nilayam, the Poes Garden residence of Jayalalithaa, was not to Apollo because it was too risky—too many people would have known of the Chief Minister’s arrival and security needed to be taken care of.

The first call was from a seasoned medical professional in Poes Garden to Preetha Reddy, Apollo’s most familiar face and the well-regarded daughter of its founder, Dr Prathap C. Reddy. Despite her recent change in designation to vice chairperson, Preetha Reddy remains the point of contact for most of the city’s elite and is known to be accessible, helpful, discreet and dependable. She asked for an ambulance to Cathedral Road but did not disclose the destination to the driver. But, as the vehicle made its way on Cathedral Road, the destination was given to the driver.

Preetha Reddy called in the hospital’s top-of-the-line specialists in cardiology, pulmonology and intensive care, and they realised the urgency of the issue without her divulging the name of the patient. In the absence of Apollo’s foremost cardiothoracic surgeon, M.R. Girinath, his colleague, L.F. Sridhar, was called in. It helped that Jayalalithaa’s diabetologist, G. Jayashree, had reached the hospital by then. At the ER, Jayalalithaa, who was diagnosed with acute pulmonary distress syndrome, was resuscitated and a temporary pacemaker was fixed on her; she was then transferred to the Multi-Disciplinary CCU (MD-CCU) in just over an hour.

The emergency room The nature of the ER and its location, a relatively open space with entry from the road and into the hospital, and the presence of personnel from multiple specialities attending to patients wheeled in makes it possible to reconstruct the events at the hospital with the help of inputs from multiple sources. But once Jayalalithaa was moved to the second-floor MD-CCU, and since the area has been cordoned off, there was not much information filtering through, prompting the curious to try asymmetric methods to get some bits of information. The specialists were obviously not keen to indulge any curious caller, or even friends. Of course, the ethics of patient-doctor confidentiality do exist, but in the case of Chief Ministers C.N. Annadurai, M.G. Ramachandran and M. Karunanidhi, they have been flouted, more by those close to the patient than by specialists.

There was no word from the hospital or the government from the time of admission until a large part of the next day. This secrecy fuelled speculation on her health status, for the third time in two years; it first began early last year before the May 2015 Karnataka High Court verdict in the wealth case, where a lower court had convicted her, and then before the 2016 State Assembly elections. The hospital stated in a press release on September 23 that the Chief Minister was admitted with “fever and dehydration”. “Honourable Madam has no fever now and is taking a normal diet,” said the release, signed by Subbiah Viswanathan, Chief Operating Officer of the hospital, an assertion which many believe was quite baseless.

A release the next day stated that the Chief Minister continued to be “under observation”, which again was far from her actual condition, as experts battled to manage an onset of sepsis and infection. Privately, Apollo contacts let it be known to friends that they were deeply unhappy with the government forcing the hospital to put out releases that observers found unconvincing.

The opaqueness led to individuals with little first-hand knowledge of the Chief Minister’s health speculating on social media about the nature of her illness. Some even came to ominous conclusions, none of which had any basis in reality.

More speculation As speculation mounted, the hospital issued yet another release on September 25, this time worse than what it had done until then. Speaking for visual media at a one-way press conference (reporters were barred entry), Viswanathan, watched by State Health Minister C. Vijaya Baskar and Health Secretary J. Radhakrishnan, dispelled rumours that the Chief Minister was being taken to Singapore for treatment, stating that “there is no necessity at all” for that, and said that the rumours on social media were “totally false and baseless”. For good measure, the hospital added that “as per standard medical protocols, necessary investigations and tests are being done to prevent recurrence of fever”.

Soon after the “press conference”, some of the reporters waiting at Apollo received information that the Chief Minister would make an appearance on the All India Anna Dravida Munnetra Kazhagam’s (AIADMK) television channel, Jaya TV, the next day. But there was no such event in the next three days. There was no official word on her health either, leading to another round of speculation.

As speculation ran wild, the hospital issued a release on September 29 stating that the Chief Minister was “responding well to treatment”. One week had passed by since she was admitted and the hospital maintained that she had been advised a few more days’ stay at the facility for “recuperative treatment”.

On September 30, Dr Richard Beale, an intensivist from the United Kingdom, flew in to examine Jayalalithaa. An October 2 release said he “examined the Honourable Chief Minister, evaluated the various clinical reports… and had detailed discussions with the expert group of doctors treating [her]”. He “concurred with the present line of management”, the release said. And, for the first time since the Chief Minister was admitted, the hospital spoke about an “infection”. “Based on the detailed discussions which the expert group had with Dr Beale, the current treatment plan including appropriate antibiotics and other allied clinical measures are presently being continued to treat the infection.”

Dr Beale’s special interests are listed on a website as “acute lung injury, multiple organ failure, general intensive care”. A reliable secondary source said that Dr Beale was horrified by the late admission of Jayalalithaa into a hospital and had commented that it should have been done at least a week before she was finally admitted. Two independent medical experts, who have also served the government, wondered why the doctors who routinely attended on her did not flag her health issues ahead and why they waited until she collapsed. From being admitted for fever, the Chief Minister now had an infection.

A day after Dr Beale landed in Chennai, Governor C. Vidyasagar Rao reached Chennai to meet Jayalalithaa. The carefully crafted press release issued by Raj Bhavan after the visit on October 1 said that he “visited” Jayalalithaa but did not make it clear if he met or had a conversation with her, because, on October 1 too the hospital was maintaining that she was under “recuperative treatment”. “The Governor was happy to note that the Hon’ble Chief Minister is recovering well… the Governor of Tamil Nadu presented a basket of fruits and wished the Hon’ble Chief Minister a speedy recovery.” Again, he only “noted” the recovery.

The most important release that came out of Apollo, which actually said something, was on October 3. It read:

“The Honourable Chief Minister of Tamil Nadu who is undergoing treatment at Apollo Hospital, Greams Road, continues to improve. The treatment plan including appropriate antibiotics, respiratory support and other allied clinical measures are presently being continued to treat the infection.

“The Honourable Chief Minister is responding adequately to the comprehensive treatment being given to her. A team of doctors are collectively monitoring her treatment. The Honourable Chief Minister has been advised further stay in the hospital for treatment.”

The progression in the hospital’s releases from “fever and dehydration” to “respiratory support” and other clinical measures did not go unnoticed. For the first time, Apollo admitted to using “respiratory support”. This did not reveal too much because respiratory support can mean a simple oxygen mask, an advanced oxygen intake system, non-invasive ventilation, or ventilation.

The release, more importantly, said that the Chief Minister was “advised further stay”, moving away from the earlier assertions that the Chief Minister would be in hospital for a “few more days”.

The most detailed press release from Apollo Hospitals came on October 6. It spoke of a “comprehensive treatment plan” and said that “appropriate antibiotics, respiratory support and other allied clinical measures are being continued”.

The release concluded: “Based on the detailed deliberations and clinical examination, the expert group of doctors from Apollo Hospitals have drawn up a detailed medical management plan keeping in view the Chief Minister’s known history of diabetes and winter bronchitis in inclement weather. The present treatment regimen includes continued respiratory support, nebulisation, drugs to decongest the lungs, antibiotics, nutrition, general nursing care and supportive therapy.

The press releases from the hospital on October 2 and October 6 said Jayalalithaa was being treated for infection. According to a specialist, the inability to control infection beyond 96 hours in ICU settings is a cause for concern.

Adding to the mystery of the situation initially was the government press release on the Chief Minister chairing a meeting in the MD-CCU. The Information and Public Relations Department’s press release number 471 claimed that the Chief Minister “convened a meeting between 4:30 p.m. and 5:30 p.m. today (27-9-2016) in her hospital room”. This was on the Cauvery issue.

The release, curiously, went on to say: “The Hon’ble Chief Minister dictated the speech of the Hon’ble Chief Minister, which will be read out at the meeting by the Chief Secretary to the Government.”

Apollo’s handling of the situation had many serious consequences. Three different sources confirmed that some of Apollo’s curious staffers logged in with their personal IDs to access the Chief Minister’s medical records. A photograph of one medical record taken with a mobile phone went viral on social media. There was nothing seriously wrong in any parameter in this particular report. Apollo cracked down on the wrongdoers and disciplinary action was initiated against a shocking number of people who tried to access Jayalalithaa’s medical records: multiple sources insist that this is under 40 but one puts it at closer to 100. A staffer from Delhi was among those from other centres who tried to access the records. The Tamil Nadu government’s cyber cell came in to plug the leaks, making rumour-mongering worse. Senior specialists and all doctors were asked to refrain from talking about the Chief Minister. Most of them went off their mobile phones after word spread that the phones of all Apollo employees were under surveillance.

Crowds gathered outside Apollo every day and a variety of prayers were offered for Jayalalithaa’s recovery. Some of her die-hard cadres refused to leave the premises even after nightfall, and continued to remain outside the hospital for days on end. Some of the cadres who gathered at Apollo began venting their ire at the hospital: if what they claim in their benign press releases were true, then their ‘Amma’ should have been home by now, one of them said. Memes in social media “condemned” Apollo for making the Chief Minister stay in the hospital longer than required.

The word “popular” is inadequate to describe the love and devotion that Jayalalithaa’s following has towards her. She is not merely loved and admired in Tamil Nadu, she is more than a leader to cadres in the State’s largest party, the AIADMK. In many campaigns, she had told people that she was a mother to them, and the crowds roared in acceptance. She achieved what no leader before her, barring the icon of the poor in Tamil Nadu, M.G. Ramachandran, had achieved—winning back-to-back terms in the State. In the two and a half decades that she has been at the party’s helm, the AIADMK grew from being an also-ran in New Delhi to becoming the third largest party in Parliament, with 50 MPs. She is easily the tallest leader in Tamil Nadu in terms of electoral victories or the ability to connect with people merely by putting up her hand and showing the victory symbol, which, in Tamil Nadu, stands for two leaves, the AIADMK’s symbol. Hence, the interest in Jayalalithaa’s health is across the board and a matter of frenzied debate all over the State.

The rumour-mongering over her health led to many businesses repeatedly closing early, schools asking students to go home earlier than usual, and people stocking up on food, fuel and water, apart from affecting the livelihood of countless daily wage labourers and pavement shops.

Some mischievous elements even circulated a fake website of a university’s holiday announcement fearing the worst.

There was even the case of a “picture” of Jayalalithaa in an intensive care unit being put out. On closer examination, it was found that the picture was from a hospital in Peru and clicked on August 20, 2009.

Positive spin There was also some positive spin from interested elements. One tweet went thus: “came to know from one my friend cousin working in Apollo Greams road.. Jaya is fine.. Trustable source.”

Another was an audio file of Jayalalithaa, which most journalists who recognised her voice said was not hers. “Now an audio msg doing rounds on #WhatsApp claiming to be that of TN CM’s...I dunno what and all people are going to do till she is in hosp,” one journalist tweeted. But in all this social media rumour-mongering, conspicuous by its near-absence was the IT wing of the AIADMK, which had, in the run-up to the elections, won accolades for effectively countering the opposition Dravida Munnetra Kazhagam’s (DMK) vastly superior social media campaign ( Frontline , June 10, 2016).

The government machinery was overanxious to prove that the Chief Minister was continuing her office and party work. On September 26, as if to prove that all was well with the AIADMK leader, the party released the first list of candidates for the local body elections. Later, a second list was released.

On September 28, the government announced Rs.476 crore as bonus for government employees. The same week, foreign travel of two Tamil Nadu cadre Indian Administrative Service (IAS) officers was also cleared.

The Chief Minister’s continuing hospitalisation and the overzealous security of the Tamil Nadu Police meant that regular patients had serious difficulties in reaching the hospital. Some patients, who had no appointments, were asked for proof of identity; cars could not get to the porch of the hospital—for a few days patients were dropped off about 500 metres away at the junction of Greams Road and Greams Lane (the lane leading to the hospital). Later, a buggy was made available to transport patients but it is not easy to access Apollo past the security, the praying and sometimes dramatic party members and the crowd of reporters.

“Business should be down at least 50 per cent,” said a senior consultant. “I am seeing very, very few patients. Those who are well enough to put off visiting the hospital are doing so,” he added. The drop in patients, and even worse, the perception that Apollo cannot be accessed, forced the hospital to issue a release. On October 3, Apollo’s strange press release said:

“Apollo Hospital, Greams Road is completely functional. All our doctors and hospital facilities are available. Patients can visit us anytime. Kindly book appointments using 044 60601066. “For 24x7 emergencies, please call 1066.”

The release was signed by the Chief Operating Officer.

Leaders of the opposition parties were concerned over the level of rumour-mongering. Soon after Jayalalithaa was admitted most leaders wished her a speedy recovery. Her prolonged hospital stay and the lack of briefing for all leaders (in most other States, and even in the event of a war, the opposition is informed) led to the leaders issuing public statements. This led to a flurry of activity, with some leaders, including DMK president M. Karunanidhi, asking for the actual status of her health.

Karunanidhi urged the AIADMK to release a photograph to prove that she was not in a critical state. The party rejected the demand. Viduthalai Chiruthaigal Katchi (VCK) leader Thol. Thirumavalavan visited the hospital to make inquiries, and later told the press that he was informed that she was progressing well. He could not meet her either.

“It is bad that rumours are doing the rounds. Some people start these on purpose. And some mindlessly forward it without thinking of the consequences,” said the DMK’s parliamentary party leader, Kanimozhi. “We understand that she has a right to privacy. But a lot of people are really concerned. So, if someone responsible keeps the people of Tamil Nadu updated on her health, it will reassure people,” she told Frontline . Wishing the Chief Minister a speedy recovery, she said: “Everyone wants the Chief Minister to get well and return to her duties hale and healthy.”

On October 4, the Madras High Court concurred with the “public interest” argument, and opined that an official statement “will reduce the anxiety of people”. The petitioner, “Traffic” Ramaswamy, approached the High Court, requesting it to “urgently” hear his case. Despite protests from the government, the judge observed that there was a lot of interest among the public on the issue of the Chief Minister’s health. In a great relief for the AIADMK camp, the First Bench of the High Court dismissed the petition on October 6.

But the entire episode raises three main questions: one, the issue of privacy versus the public interest; two, the running of the government in the absence of the elected Chief Minister; and three, making medical calls for an important constitutional functionary who has no declared blood relations.

The right to privacy flows from the right to freedom under Article 19 and the right to life under Article 21 of the Constitution. In State of Uttar Pradesh vs Raj Narain , the Supreme Court held that Article 19(1) (a), apart from guaranteeing freedom of speech and expression, guarantees the right to receive information on matters concerning the public interest (1975 AIR 865).

There are similar cases where the cause of public interest is prioritised over that of privacy. In the Right to Information Act, 2005, under section 8 (1) (j), there is an exemption that constitutional functionaries can avail themselves of: it exempts revealing personal information not associated to any public activity or of public interest or which would cause an unwarranted invasion of privacy.

While the privacy versus public interest issue will be debated, and litigated again, in future, the more important issue pertains to the government functioning in a State when its Chief Minister is on a ventilator. No one is sure who gave the orders on September 28 regarding the bonus for government employees or approving the foreign travel of the IAS officers, although all these are attributed to the Chief Minister. The claim that she convened a meeting in her “room” at the MD-CCU and that she dictated her speech on the Cauvery issue, calls for an investigation, at the very least.

The pertinent question as to who is in charge of the Tamil Nadu government remains. Finance Minister O. Paneerselvam, who was Chief Minister on two earlier occasions when Jayalalithaa was forced to step down, is listed No. 2 in the Cabinet on the government site. Though he is seen at the hospital, he is not in charge of the treatment being given to Jayalalithaa. Multiple sources told this correspondent that the person making medical decisions on behalf of Jayalalithaa is a relative of Sasikala, a plastic surgeon married into her family. It is again unclear who picks the options for treatment available, though a few days after her admission a team of doctors met regularly to discuss the way forward.

On October 6, a three-member team of senior specialists from the All India Institute of Medical Sciences, New Delhi, comprising the pulmonologist G.C. Khilnani, the cardiologist Nitish Naik and the anaesthetist Anjan Trikha flew in to examine Jayalalithaa. Dr Khilnani is the personal physician to Vice President Hamid Ansari and Dr Naik has been on the team that treated former Prime Minister Manmohan Singh and Congress president Sonia Gandhi. Dr Beale is also expected to be back at Apollo for further consultations.

As celebrated medical specialists fly in and out of Chennai and the speculation over the Chief Minister’s health continues, the question remains as to why the country has not established an automatic standard operating procedure that kicks in whenever a constitutional functionary is temporarily out of action.