Gorakhpur is a wake-up call, but do we care?

Some things are not negotiable: the right to life and well-being, for one. These are basic expectations of citizens from their governments, and those governments that cannot fulfill them do not have the credibility to govern.

It is important to view the Gorakhpur tragedy in this larger context and not confine the debate to the symptoms of the deeper malaise – the cocktail of acute infections combined with technical incompetence and loss of values. So, till the causative factors are not resolutely dealt with, Gorakhpurs will continue to occur.

Story of Gorakhpur

Extensive media coverage for over a week has brought out enough information to deconstruct the story. It is clear that both viral infections like Acute Encepahalitis Syndrome (AES), of which Japanese Encephalitis is one, and bacterial infections like scrub typhus, afflicted the children admitted for treatment at BDR Medical College hospital. They travelled long distances to reach Gorakhpur, for want of facilities – public or private – with the capability to treat them near their own places of dwelling.

Overcrowding, lack of doctors, nurses and adequate equipment, gross mismanagement, combined with conflicts of interest such as parallel private practice, and unhygienic conditions, all severely compromised the quality of care at BRD hospital. While some deaths may have been unpreventable, many could have been prevented if the hospital was not so chaotically governed and, more importantly, if there were facilities with the capability to diagnose, treat and stabilise the sick closer to their communities.

Lessons

The situation can be corrected, provided there is political will. All that is required is to ban private practice by government doctors and incentivise good outcomes, provide the required funds, fill vacancies and, most importantly, induct professional managers to run the hospitals – to maintain cleanliness, hygiene, sanitation, inventory control in accordance with protocols, enforce guidelines defining clearly the levels of responsibility and accountability, and use technology for treatment, computerisation and digitisation of hospital records. This is not rocket science. What’s required is a strong political direction, insulation from political interference and close monitoring, as was done in the case of Delhi Metro.

Primary care enhances equity

But the above measures, including handing over 20 government hospitals to private investors, will have a marginal impact as hospitals only address full-blown disease. If not 60, at least 20 will continue to die. Given the non-existence of primary care, a huge disease burden, restricted public investment and wide disparities in the quality of life between the rich and the poor, what must be the role of the state? To deal with public goods and thereby ensure that children do not fall sick in the first place, or to palm off all responsibility by leasing out government hospitals to private investors and push insurance-based hospital delivery systems? The solution to Gorakhpur will depend on the choices made.

Other countries around the world, too, had to face such dilemmas and make tough choices. All, without exception, sought to eliminate, contain and reduce incidence of communicable and infectious diseases by strengthening the primary healthcare system in the spirit of Alma Ata, which extended the definition of primary healthcare not only to medical interventions but also to concerted action on social determinants of health, providing universal access to safe water, good nutrition, clean air and sanitation.

Despite being a signatory to the Alma Ata declaration of 1978, India reneged on implementing its vision. Nearly 40 years later, India still has 15 lakh children dying every year due to diarrhoea and acute respiratory infections, a reported 10 lakh due to air pollution, 44% of people defecating in the open against zero in China and Sri Lanka, a resurgence of TB in its more virulent and expensive-to-treat form, and so on.

Some 36% of the country’s disease burden is still due to communicable diseases that disproportionately affect the poor living in urban slums and rural villages. Despite the total combined strength and policy attention of the central and state governments over the past decade, inadequate budgets have led to India’s failure to achieve the UN Millennium Development Goals for maternal, infant and child mortality. Singular attention to this goal did bring in significant gains, but it has been at the cost of attention to disease control programmes.

What Next?

The choice is clear. Governments must focus their energies on providing comprehensive primary healthcare. While only 20% of the services that ought to be provided in primary health settings are currently available, longitudinal studies of Brazil, Denmark, UK and even the US have convincingly demonstrated that universal access to comprehensive primary healthcare services enabled a 30% reduction in emergency admissions, hospitalisation and heart ailments, besides stabilising and reducing diabetes and hypertension, etc.

Building health systems on weak foundations of patchy primary healthcare and weak disease surveillance systems is not a sustainable model. The recent ebola crisis in West Africa convincingly showed that the epidemic was finally contained by community engagement and community health workers, not hospitals and the billion-dollar foreign aid that poured in.

India’s rich and the poor are equally vulnerable to infectious diseases. What is needed is to spend 2% of our GDP on strengthening primary healthcare service delivery by filling up posts with appropriately trained personnel and launching a war on social determinants of diseases.

Further neglect of these measures can risk our health security. The bottom line is, however, do we care?

 The writer is former Secretary, Union Ministry of Health, Govt. of India, and author of ‘Do We Care? India’s Health System’.