As per the story of Krishna’s birth, seven of his elder siblings were killed as babies by Kamsa who was in mortal fear of Devaki’s progeny born in prison. It is a tragic irony that many babies and young children died in controversial circumstances in a Gorakhpur hospital on the eve of Janmashtami, which celebrates Krishna’s birth. Reforms are needed in our health system to ensure that hospitals meant to protect life do not become prisons where life is snatched away.
It is important that the Gorakhpur tragedy is not marked as a mere moment of evanescent public outrage that swiftly gets buried in the shifting sands of political bickering, or is abandoned by fickle media attention that hurriedly moves to yet another failure of public services. The tragedy must compel us to seriously review the sorry state of our public health system, and earnestly implement remedial reforms to enhance its access, effectiveness, empathy, impact and accountability.
Tapering, and then complete cut-off, of oxygen supply due to unpaid bills is the cause célèbre that triggered the din and drama of acrimonious TV debates. This callous act represents merely the tip of the iceberg that is sinking the ship of our health system. The inability of our dysfunctional health system to deliver easily accessible, appropriate, quality assured and affordable healthcare in an effective and equitable manner is the continuing story that calls for serious debate and committed corrective response.
Gorakhpur and neighbouring districts of Uttar Pradesh have economic, health and other social indicators that compare poorly with national averages and tell a story of neglected development. Infant mortality is high, and many of the surviving children are malnourished. Viral encephalitis has been rampant in the area. Even though vaccination against Japanese encephalitis provided some protection, the problem continues with other forms of encephalitis and undiagnosed scrub typhus implicated as other causes of severe illness. Mortality is high, when undernourished children with low resistance are hospitalised for critical care, and life-support becomes essential in severe cases. The deaths in Gorakhpur represented a mix of clinical diagnoses, including pneumonia. In many such cases, oxygen was an essential part of respiratory support. While the underlying disease is the recorded cause of death, interruption of respiratory support could have stalled recovery and hastened death. It must be regarded as a contributory cause, at least in some cases. The truth about why the oxygen supply ceased must be uncovered and criminal culpability fixed. However, the response should not end there. This shocking event should serve as a jolt to our collective conscience and stir us to examine why child health indicators are so poor in some regions of our country and why public heath systems are configured for poor performance in many states.
The catalogue of public health failures in Eastern Uttar Pradesh is extensive: high levels of childhood malnutrition that arise from improvident early motherhood and poor feeding practices, creating high vulnerability for acquiring infections and succumbing to them; insanitary living environments that multiply myriad microbes and breed insect vectors that transmit diseases from animals to humans; deficient epidemiological knowledge of changing disease profiles and emerging infectious agents; inadequate surveillance systems that fail to provide accurate real time data; limited presence and poor performance of primary care facilities in the public sector; non-participation of private health care providers in disease reporting and variable quality of primary care provided by them.
The list grows as we examine the state of hospitals in states with weak health systems: inadequately-resourced district hospitals in many areas; overcrowding representing both low bed-strength and failure of primary care as an efficient filter; poor hospital management practices where busy clinicians have to perform many administrative roles; shortages of specialists and allied health professionals; lack of standardised clinical protocols and operational practices; opaque and corruption-prone procurement systems; absence of electronically maintained and regularly monitored stock inventories; underpaid government doctors permitted to run private clinics; lack of efficient referral–follow-up linkages with primary health services.
Many of these problems result from concurrent failures in policy, planning and regulation: low public financing for health; underinvestment in production and equitable deployment of healthcare providers of different categories and competencies; low priority for creating and utilising public health expertise; antiquated methods of hospital management; centralised bureaucracies that do not delegate authority to hospital managements; lack of quality audits; vagaries in approach to and vacillation in implementation of universal health coverage. When we look at health beyond healthcare, lack of overall progress and glaring inequities in the social indicators of health explain why so many fall ill in the first place.
The directory of remedial responses, too, is large, but presents a clear agenda for action: increase public funding for health at both central and state levels; prioritise increased health expenditure on primary health services, especially through technology enabled allied health professionals functioning from sub-centres close to the community; ensure success in the sanitation and clean drinking water missions; improve child nutrition through interventions that extend from pre-conception to school years; strengthen epidemiological and surveillance data systems; upgrade district hospitals and link new medical and nursing colleges to them; raise pay scales of government doctors and bar them from private practice; invest in developing and deploying expertise in public health management and hospital management; mandate credible, transparent and accountable procurement systems with electronically monitored inventories of drugs and consumables; quality audits, with technical, administrative and social audit components. Also crucial is the political determination to design and deliver universal health coverage as an overarching framework of health system reform.
The Gorakhpur event is an abomination, but not an aberration. In December 2014, just before the new year, the country was horrified by the sterilisation deaths in Chhattisgarh and the eye camp blindings in Punjab. We also remember the hospital fires in Kolkata and Bhubaneswar. Other unreported tragedies occur regularly on a smaller scale in all parts of the country. The Gorakhpur tragedy is yet another publicised chapter in the dismal tale of health system failures. However, this latest tragedy must steel our resolve to reform and revitalise our health services to prevent recurrence of similar failures.
“Nobody has been corrected; no one has known to forget, nor yet to learn anything” is a comment of French Naval Officer Charles Louis Etienne in 1796, which the renowned diplomat Talleyrand paraphrased later while deriding the Bourbons with the dismissive phrase “they have learned nothing, and forgotten nothing.” It appears that we too have not learned much from the tragedies of the past in correcting the fault lines of our dysfunctional health system though they lie nested in our memory. Gorakhpur must change that. Combining political will with professional skill, we can transform our moribund health systems. We owe it to the innocent children who lost their lives because of an unconscionable failure of society to protect them. Overcoming partisan passions, we must all now pursue the right path and do our duty to restore justice, as Krishna grew up to remind us in the Gita.