Gorakpur Hospital Tragedy: What was left unsaid!

Raghuraj S. Hegde

While opinions flow through print, television and social media regarding who is responsible for the deaths of the 70 children in a single hospital over such a short period of time, no one seems to be talking about the core issues regarding public healthcare in India. There has been a carefully constructed distance between the ruling state party and the tragedy that has unfolded. This is to ensure that the Yogi Adityanath led BJP is not directly blamed for the tragedy. While one can understand why the government would be in this defensive mode what one fails to understand is why our system being questioned is seen as a bad thing.

• Do our governments owe no responsibility or accountability for healthcare coverage for the masses?
• Is the cost of a human life determined by the ability of that human to pay?

I also want to provide clarity for those who are vehemently defending the government and CM with the following arguments:

• Government hospitals have always had poor infrastructure and hospital deaths are very common in India- so why blame the government for this “one isolated incident”?
• Doctors and hospital administrators were responsible for the deaths- why should people blame the government for that?
• The BJP government is only 5 months old. How can they be held responsible for the previous decades of misrule and poor governance?
• The government has no money (the most amusing argument) and hence cannot match private health infrastructure.

I will answer those at the end of this piece but shall we get the facts first?

India’s Under 5 Mortality Rate (U5MR), Infant Mortality Rate (IMR) , Neonatal Mortality Rate (NMR) is among the highest in the world since several decades and it has not declined in the time since.

Just for comparison let us just compare with China as it started out at almost the same time as Independent India with a population to match during the same time period. Do remember that China’s GDP per capita was less than India’s till the early 1990s. I have used this neat tool from the UNICEF website to compare child mortality estimates between India and China.[1]

The top three lines on the graphs belong to India and the bottom three belong to China. One can see how poorly we have performed in terms of healthcare since independence.

IMR is not an isolated statistic. IMR infact represents the health of our healthcare system. A high IMR is indicative of a poor healthcare system. Not surprisingly, India has one of the highest IMR in the world comparable to some of the most strife ridden African countries.

Ali Medhi — Head of Health Policy Initiative at ICRIER, Delhi gives some interesting figures in his recent article about the Gorakpur tragedy.[2]

India has been the world’s largest contributor to all levels of child deaths since 1953 — the first year for which we have Indian data available. Starting out with nearly 4.7 million deaths a year under the age of five years (U5), it took us almost three decades to bring them down to 4 million a year.

Between 1969 and 1979 China reduced U5 deaths by 2.4 million, the highest in a decade in any country in recorded history. The beginning of the Millennium Development Goals (MDGs) did accelerate the pace of progress in India, but China again outperformed us. As did our neighbours Maldives, Nepal and Bangladesh between 1990 and 2015, to achieve their MDG targets on child survival.

The story has been similar at lower levels of child survival as well. At the neonatal level (ie during first 28 days of birth), the Bimaru states accounted for 55% of all deaths in the country in 2011 — UP (27%), MP and Bihar (10% each) and Rajasthan (8%) — and 15% of the global burden. While China performed even better at this stage, with a 90% decline in number of neonatal deaths during the MDG period, we had 695,852 neonates dying in 2015 — more than 7 times China’s.

As stated in my recent article How does healthcare work in your country?:

Public healthcare expenditure via government funding is around 1.3% of GDP — which is among the lowest in the world.[3]

Some more relevant facts pertaining to healthcare in India, the BJP and the Gorakpur tragedy:

• Health is a state subject not a union subject, so healthcare is the responsibility of the state government.
• The central BJP government slashed the healthcare budget by 20% in it’s first budget after coming to power in 2014- India slashes health budget, already one of the world’s lowest and has been reducing it every year
• Yogi Adityanath is a 5 time MP from the Gorakpur consituency where Japanese Encephalitis is endemic since 3 decades. Despite being an MP for such a long time, even civic infrastructure projects in the region are in poor conditions and sanitation levels are abysmal in the region. Yet he has the gall to blame sanitation and hygiene for the deaths.
• Japanese Encephalitis kills nearly 1500–2000 children every year in India-500 of those in the Gorakpur region alone. The deadly virus is spread by the mosquito as a vector. Mosquito as we all know breeds in places where there is poor hygiene and sanitation. The disease is known to be fatal to the most malnourished children of the community. Public sanitation and child nutrition comes under the direct purview of the state government.
• The administration has known about the oxygen shortage from the beginning of August as seen from this ANI report detailing letters written to the authorities- the principal, Chief Superintendent and nodal officer of the NHRM. However all of them were so full of greed that they silently watched as the oxygen supplies depleted.

Now let me come to the arguments that have distanced the government from any responsibility. I think the following paragraphs will bust those arguments.

By pinpointing the tragedy to a few causes like lack of oxygen or corrupt babus and doctors or greedy suppliers, unclean environments- the government is oversimplifying the problem as it often does. The problem is the broken system and not individual issues. The public healthcare system in states like UP, Bihar, Odhisha and West Bengal are so terrible due to years and years of neglect. This has given rise to corruption among healthcare providers because private healthcare centers have sprung up everywhere in those states and holding the population to ransom because no one wants to go to a government hospital to die. This coupled with high proportion of unemployment in these states makes sure that people who are not able to afford private healthcare are at the mercy of the bursting at the seams- public healthcare delivery system. Many of the doctors working in the government hospitals are corrupt and siphon off funds meant for public health.

The talk of the lack of funds at the hospital’s disposal seems to be a load of lies as seen in from data provided in this article.

The lack of payment by BRD Medical College does not seem to be restricted to the oxygen supply company. The salaries of at least 400 medical personnel who are involved in the treatment of encephalitis at the medical college have not been paid for many months. Doctors at the physical and medicine and rehabilitation unit have not been paid for 27 months and neonatal unit staff have not received their salaries in six months, it said.

The reason for the lack of payments is unclear. In 2014, the BRD Medical College received Rs 150 crore — Rs 120 crore from the Centre and Rs 30 crore from the state government — under a scheme to upgrade medical college institutions under the Pradhan Mantri Swasthya Suraksha Yojana.

In October 2016, The Times of India reported that BRD Medical College was among several hospitals in the state that had not fully utilised funds allotted to them under the state government’s Asadhya Rog scheme. BRD Medical College had used just Rs 15.56 lakh of the Rs 4.5 crore that was allocated to it three years earlier in 2013.[4]

Clearly someone else is eating up the money that was meant for improving infrastructure and paying salaries of medical personnel. It is an open secret in the public healthcare sphere that to release government funds, enough money filled suitcases have to exchange hands.If you don’t pay doctors and other medical personnel for months together, they will obviously find less ethical ways to earn their livelihood as they also have to put food on the table. Doctors will do private practice even though they are not supposed to as they need pay their bills.

For such a large state such as UP, there are only 25 medical colleges, out of which 15 are private medical colleges.[5] Clearly those medical colleges are not enough for the most highly populated state in India. We need more government hospitals, more government doctors, more healthcare workers and better healthcare facilities- in these type of under-served areas. Governments should prioritize public healthcare as electoral reforms and not farmer loan waivers to woo voters. The priorities of the UP government can be gauged by the fact that they have now have cow ambulances and hospitals for cows in UP but no new government hospitals for humans who cannot pay. The cost of a human life in India has gone below the cost of a cow’s life. In Yogi Adityanaths Uttar Pradesh, cows get an ambulance service

In this tragedy, Japanese Encephalitis -on which the death have been blamed on- can be reduced drastically just by improving the sanitation, hygiene, vaccination, public education and improved nutrition. If the civic bodies had concentrated on those basic and less expensive things, many of those unfortunate children who died would not be in the I’ll fated hospital in the first place. If the Swatch Bharath Abyiyan program was followed to it’s spirit, the government would not have blood on it’s hands now.

Governments cannot put their hands up in the air and say. “We are overwhelmed and under-resourced”. The government’s job is to look for solutions. They were elected for that purpose- to take care of it’s citizens. Their job is not do the finger pointing as if they were a kid caught with his hands in the cookie jar. It is their job to put their hand up and take responsibility. In any other part of the world, this type of state negligence would be considered state sponsored murder and many of the ministers’ and officers’ heads would roll.

But not in India!

They have predictably found a few scapegoats to blame the debacle on, successfully diverted the issue so far away from the real problems that things will be conveniently forgotten by the public and the media soon. The system however remains the same and new corrupt people will come to take the place of those who vacated their places or the present scapegoats will get away using the same corrupt state machinery to reclaim their old spots.

Not one person from the government has taken responsibility for this tragedy and there was not even a token statement that they will take steps to prevent this from happening again. While the honorable prime minister of our country has time to tweet about even smaller international tragedies, this massacre in a single government hospital in his own country doesn’t find any mention.

To fix a problem, one needs to acknowledge the problem. If you keep denying to see what the problem is, you will never fix anything. As I pointed out earlier, we have already missed the healthcare bus several decades ago and now we are not even bothered to catch up with it!

Originally written as an answer to What are your thoughts on death of more than 70 children due to lack of Oxygen in Gorakhpur hospital under the BJP government? on Quora

Footnotes

[1] CME Info — Child Mortality Estimates

[2] http://blogs.timesofindia.indiat...

[3] Japanese encephalitis to Superbug NDM-1: the diseases that attacked India in 2014

[4] A tragedy foretold: The questions Uttar Pradesh government must answer for Gorakhpur deaths

[5] What the Gorakhpur Tragedy Tells Us About India’s Public Healthcare System

Originally published at indianmedicalcareers.quora.com.