Tale of neglect

THE death of almost 60 children, including infants, in the government-run Baba Raghav Das Medical College Hospital in Gorakhpur within a span of 48 hours raises several issues relating to the state of public health in the country, especially because the National Health Policy 2017 envisages increasing spending on health only to 2.5 per cent of the gross domestic product (GDP) by 2020 and leaves it to the private sector to fill critical gaps. Only an increase in expenditure on health and a robust and accountable public health care system can be trusted to fill critical gaps. The fact that a huge number of infant and child deaths take place even now—and not all are attributable to encephalitis—should be a matter of grave concern to both the Central and State governments.

The alleged cause of the deaths of the children on August 10 and 11 was asphyxia because of the unavailability of sufficient oxygen. The term “alleged” is being used as the cause is the subject of inquiry at several levels even as a political slugfest is under way to determine who was responsible for this tragedy. Independent sources in Gorakhpur told Frontline that the deaths could be a result of various types of enteroviruses causing Acute Encephalitic Syndrome (AES) in the children.

Successive Central and State governments are culpable to a certain extent; but the current State government, headed by Yogi Adityanath of the Bharatiya Janata Party (BJP), cannot escape responsibility for the deaths. So far, it has indulged in a futile blame game and tried to pin responsibility on the hospital administration. On August 22, a committee headed by the Chief Secretary submitted its report to the Chief Minister. The report, a copy of which is available with Frontline , has short-, medium- and long-term recommendations. It has asked for a criminal investigation against Rajiv Mishra, Principal, BRD Medical College Hospital; Dr Satish, head of the department of anaesthesia and child health and in charge of the oxygen supply; Dr Kafeel Khan, in charge of the 100-bed Acute Encephalitic Syndrome ward; and Messrs Pushpa Sales Private Limited, the oxygen supplier. It has also recommended an inquiry into the “concealment of facts” by Dr Kafeel Khan, accusing him of going against the rules of the Indian Medical Council. Apart from this, it has recommended an inquiry under the Prevention of Corruption Act against the Principal, his wife Purnima Shukla, and two others. A special audit by the Comptroller and Auditor General (CAG) of the medicines bought over the last three years has also been recommended. The Chief Minister has accepted the recommendations and ordered the departments concerned to proceed speedily against them, adding that that no one will be spared. The report has recommended creating medical and paramedical posts to fill the shortages in all government medical college hospitals and making budgetary provisions for the same. It does not mention the cause of deaths anywhere.

Acting on an inquiry, the government removed Anita Bhatnagar Jain, Additional Chief Secretary (Medical Health), from her post and suspended the principal of the medical college. Anita Bhatnagar Jain was held responsible for the delay in the payment of dues to the oxygen vendor. Separately, responding to petitions demanding a high-level probe, a bench of the Allahabad High Court directed the government to place before it the committee’s report.

A three-member team of the Indian Medical Association (IMA) comprising Dr K.P. Kushwaha, former principal of the medical college and head of the paediatrics department; Dr Ashok Aggarwal, national vice president of the IMA, and Dr B.B. Gupta, president of the Gorakhpur branch of the IMA, conducted an inquiry into the deaths. While it did not find the administrative head and the paediatric physician in charge of the ward guilty of clinical negligence, it did observe that the supplier of liquid oxygen had not been paid his dues for over six months.

The inquiry committee also found that the hospital was overcrowded and that there was a shortage of paramedical and other medical staff such as nurses and doctors, especially paediatricians. The IMA-appointed committee did not recommend any drastic action against the doctors and the administrative staff but proposed an administrative inquiry. It did attempt to seek out the views of the doctor on duty, the administrative head, and the college principal, but they did not appear before it.

Various inquiries have apportioned blame and responsibility in different ways. A team of doctors sent by the Central government found that unavailability of oxygen was not the reason for the deaths even though there was overwhelming evidence of requisitions made to the Department of Health for release of funds, which were sent after considerable delay. The Chief Minister, too, declared on Twitter that oxygen supply was not the main reason. “To expect the vendor to hang around for six months is a little unfair. The payments were undoubtedly held up,” said a doctor involved in one of the probes. The Chief Secretary and others have demanded that those responsible, including Ministers and heads of departments who ignored the requisition to release money to pay the oxygen supplier, be sacked.

It is also being argued that there is nothing unusual about the high number of deaths in a region and a hospital that catered to several districts in Bihar and had patients coming in from Nepal as well. Doctors Frontline spoke to in Gorakhpur said that children who had good immunity and were better nourished had a higher chance of survival. In 2012, the mortality rate in the region dipped to 15 per cent from around 35-40 per cent earlier. That same year, children were administered immunoglobulins, resulting in many lives being saved. These medicines, doctors told Frontline , were expensive, costing Rs.1 lakh per patient, but the then government, because of the persistence of the hospital administration, managed to provide the medicine to the children.

An analysis of the Uttar Pradesh government’s Budget shows that there has been a significant hike in the medical and health budgets from 2015-16 onwards. The “actuals” for 2015-16, when the State had a Samajwadi Party government, was Rs.12,104 crore and it saw a significant leap to Rs.17,828 crore (Budget Estimates, or BE) in 2016-17. The Revised Estimates, or RE, was Rs.15,834 crore. However, after the new government assumed office, it allocated Rs.17,181 crore, which was an increase of 9 per cent over the RE for 2016-17, but, compared with the BE for 2016-17, the amount sanctioned was Rs.647 crore less. In comparison, the percentage change (BE 2017-18 over RE 2016-17) for education (34 per cent), agriculture (813 per cent), public works (54 per cent), urban development (65 per cent), and rural development (37 per cent) showed increases. The health budget promised to introduce 712 more emergency ambulances.

Dismal picture

Data from the fourth National Family Health Survey (NFHS, 2015-16) on Gorakhpur show that only 17.7 per cent of the children received a health check-up within two days of birth from a doctor, nurse or midwife. A high percentage of births were in public facilities, indicating perhaps the dependence on public health centres.

Only 65.4 per cent of the children in the 12-23 months age group were found fully immunised against tuberculosis, measles, polio, diphtheria, whooping cough and tetanus. Only 3.8 per cent of the children in the 6-23 months age group were found having an adequate diet; 42.1 per cent under five years were stunted, 19.9 per cent were wasted and 35.2 per cent were underweight. Almost 60 per cent of the children in the age group 6-59 months were anaemic. Similarly, 45.6 per cent of the pregnant women in the 15-49 age group were anaemic and fewer than 15 per cent of the women had undergone any examination of the cervix, breast or the oral cavity. Vaccination for Japanese encephalitis (JE) was 29 per cent in the 1-15 age group. And 70.3 per cent of the children who were taken to a health facility reported fever or symptoms of acute respiratory infection.

It has been ascertained from reliable sources that of the 60 deaths, fewer than 12 were because of JE, nearly a dozen because of scrub typhus (a zoonotic disease that was identified as a source of child mortality in 2013), and the rest because of various enteroviruses. Scrub typhus is known to cause encephalitis (inflammation of the brain) as well. So it was not only JE that was responsible for the deaths in the BRD Medical College Hospital. But rather than establishing diagnostic practices within the hospital, the research units within the medical college were closed down. Work slowed down at six Indian Council for Medical Research (ICMR) projects on scrub typhus and at the National Institute of Virology unit. There was no explanation though a fund crunch was hinted at.

The low-lying plains of Gorakhpur, which nestle between the Sarayu and the Ganga rivers, are host to a range of communicable and water-borne diseases. Agriculture is the sole occupation here as in the rest of eastern Uttar Pradesh, though frequent floods disrupt agricultural work. With high levels of groundwater contamination, the region has a high rate of gastrointestinal infections too. The situation has been more or less the same since 1978 when the first outbreak of JE occurred. Until 2004, no efforts were undertaken to check the spread of the main vector, pigs and mosquitoes. The only JE vaccine-producing centre in the public sector at Kasauli in Himachal Pradesh was shut down in 1998 and imports began. While the reported cases were in lakhs, the supplies were totally inadequate, said a doctor from Gorakhpur.

Meanwhile, an outbreak of JE in Andhra Pradesh between 2002 and 2004 saw the government there swing into action, intervening at multiple levels including providing vaccine. Gorakhpur was ignored. JE cases in Assam and parts of Bihar came down owing to the supply of imported vaccines. In 2006, children and adults were vaccinated in Gorakhpur as well. In 2007, the United Nations Children’s Fund (UNICEF) reported that only 56 per cent of the children were immunised against JE. There were other enteroviruses active too. Fevers were getting more prolonged, resulting in acute flaccid paralysis. Vaccines could not be the only solution.

What is clear in this instance is that there was a shortage of oxygen for those children, including neonates, who may or may not have had JE but were brought to the hospital in a serious condition. It is widely recognised that the primary health centre (PHC) is the first point of prevention and treatment, and it has been ignored by successive governments.

State of PHCs

The continuing low budgetary allocation for health by the Centre is an indication that a major shift in thinking has not happened. It has been reported that only 30 per cent of the doctors report for duty at the PHCs in Gorakhpur. There are no patient admissions; only out-patient departments function. There is a shortage of medicines as well. Cleanliness and overall facilities provided in the PHCs are an issue. At the community health centres (CHCs), doctors are present but do not admit encephalitis cases. They are all referred to the BRD Medical College Hospital. The IMA report points out that the hospital caters not only to Gorakhpur district but is the only source of tertiary health care for as many as 16 districts. It is terribly overburdened, taking in five times the sanctioned capacity of patients. Nearly 128 doctors and paramedical staff are “outsourced” while 160 are on contract. In such a scenario, a disaster was waiting to happen.

There are, therefore, several reasons for the death of so many children. It could have been prevented had the investments been made in the desired areas. Having been the constituency of the current Chief Minister for several decades, the situation in the hospital could have been addressed earlier. The way out lies in strengthening the public health system by stepping up investment in health, both by the State and by the Centre, and making the PHCs and the CHCs workable. The “health and wellness centres” planned by the Central government cannot wait until another such tragedy strikes. To expect the private sector to fill the gaps would not only be unrealistic but pave the way for greater disasters ahead.