The Gorakhpur tragedy has two very pertinent facets and it is important to separate them. The first, obviously, is the acute face of the tragedy: the shortage of oxygen supply in the critical care unit of a tertiary care public hospital. The second is the failure of India’s public health system, which has allowed “encephalitis” to become an annual outbreak in the region.
Let us begin with the latter.
‘Encephalitis’ is a misnomer. The correct expression is Acute Encephalitis Syndrome (AES) — an umbrella term for diseases with certain characteristic symptoms. So when you hear “encephalitis” in Uttar Pradesh and Bihar mentioned in the same breath, be cautious. They are very different diseases, apart from their presentations.
From a policy perspective, this generalisation could have had disastrous public health consequences. For long, annual “encephalitis” outbreaks in the adjoining districts of Gorakhpur and Kushinagar were thought to be rooted in Japanese Encephalitis (JE). JE is caused by a virus that is found in pigs, water birds and livestock, and is transmitted to humans by mosquitoes. UP has introduced JE vaccination in its routine immunisation schedule, and has organised, for several years now, special vaccination drives before summer. In 2013, when this writer was reporting the outbreak for The Indian Express, the administration in Gorakhpur boasted of over 90% vaccine coverage. But somewhere around mid-August, these were the numbers: a total 226 admissions and 59 deaths in Gorakhpur, and 248 cases and 43 deaths in Kushinagar. Of these, five patients in Gorakhpur and eight in Kushinagar had tested positive for JE.
In 2012, however, the National Institute of Virology (NIV) identified 100 isolates of organisms called enteroviruses (EV) — specifically the human EV 89 and EV 76 types — from 1,000 samples of cerebrospinal fluid (CSF) from children admitted to Gorakhpur’s Baba Raghav Das Medical College Hospital. As scientists told this writer then, 10% positivity is considered a great testing success in CSF samples. These enteroviruses spread through contaminated water, and trigger symptoms very similar to JE. And they are, of course, included under the ambit of the generalised, convenient term, ‘AES’. Thus, in Gorakhpur, most children did not get sick after being bitten by mosquitoes carrying the virus; they merely had very bad quality water.
In Bihar the same year, scientists from the US Centers for Disease Control and Prevention, and other experts argued for classifying “encephalitis” outbreaks as Acute Neurological Syndrome (ANS) after carrying out their first investigation in Muzaffarpur district. They published the results of their investigation in The Lancet this year, identifying a toxicological root in the litchis grown in the district.
Clearly, epidemiological investigation, a key discipline in public health, and central to understanding the root of “mystery” diseases, has been chaotic in both UP and Bihar for almost a decade. The system has been reactive — busy treating symptoms rather than getting decisive, coordinated answers for, and targeting the roots of, disease.
In 1981, epidemiologist Geoffrey Rose described a phenomenon called the ‘Prevention Paradox’ — the public health dogma that preventive interventions that benefit entire populations have very little or no tangible impact on individual health. Thus, they are not appreciated enough, even though they save the public health system a lot of money.
Vaccination is perhaps a more individual approach to public health. Every child is vaccinated, and there is the psychological impact of benefitting from an intervention. Obviously, when the target is a vaccine-preventable disease like polio or even JE, vaccines work wonders, and their importance cannot be overemphasised in population health. However, in this case in UP and Bihar, should JE vaccination have been made the only poster public health intervention? In Gorakhpur, NIV scientists have been pointing to enteroviruses since 2005-06. But neither the UPA’s erstwhile Total Sanitation Campaign nor the present government’s Swachh Bharat Abhiyan targeted this actively.
Now consider the acute events that led to the present crisis. It is a blot on India’s public health system that handheld “ambu-bags” are a characteristic feature of government hospital emergencies — not just in “interior” districts like Gorakhpur, but also in Delhi and Mumbai. This is a commentary on how lost we are in health financing, payment and delivery mechanisms, despite many continuing policy experiments.
So, after all the PPPs, performance-based incentives, RFPs and RFQ models, and the debates around universal healthcare, social insurance, single- and multi-payer payment systems, it is a travesty that not only was the one tertiary health facility in a 300-km radius dependent on a contract and a subcontract for the supply of oxygen in its ICU, dues of less than $ 10,000 were delayed so long — and that finally, despite being cleared by the state Health Department, payment to the supplier was held up in administrative bottlenecks.
But then again, this is no surprise. One of the images that stands out for this writer from her reporting in 2013 is that of the new 100-bed AES ward in BRD College, with 25 new ventilators purchased that year, but lying unused despite the growing number of patients, because the installation of oxygen pipelines had missed deadlines.
There is a slide that Harvard health economist Peter Berman always uses in his classes. It is from Alice’s Adventures in Wonderland:
“Would you tell me, please, which way I ought to go from here?”
“That depends a good deal on where you want to get to,” said the Cat.
“I don’t much care where…,” said Alice.
“Then it doesn’t matter which way you go,” said the Cat.
“…so long as I get Somewhere,” Alice added as an explanation.
Health systems scholars, funding agencies and policy thinktanks like the World Bank, IMF, and Oxfam have many disagreements. But the one thing that most agree on is the need for evidence-based action, as opposed to running in the dark, in search of Alice’s “somewhere”.
For every public health problem, this entails determining a goal, identifying an intervention that can help achieve that goal, ensuring a monitoring system to check for problems and course correction along the way and, finally at its conclusion, having a system for evaluating what the programme achieved, and where it failed. Introducing these seemingly logical steps for health policy decisions remains a challenge in India.
Experts like the Harvard economist William Hsiao have long argued for identifying “control knobs” to overhaul health systems at the roots, against knee-jerk approaches to policy conundrums. Many of these classic control knobs can be traced to the present escalation: “financing, payment, regulation, organisation”. These could be the routes towards targeted policy solutions to course-correct.
It must be pointed out here that UP, or even India, is no exception. Countries with higher income levels and with far bigger health budgets, too, are struggling to identify the right models for financing and delivering public health. Among OECD countries, the United States is a classic example of poor health outcomes despite gross overspending on health. It is now well established that while health budgets are critical, spending money alone is not enough. This is, of course, not to undermine the problems resulting from sectors like health and education historically getting the short end of the stick in India.
There is increasing realisation, however, that public health delivery is a complex story, entrenched in cultures of governance, monitoring and evaluation mechanisms on the one hand, and social structures, gender roles, income levels and inequalities on the other. The latter are classified under the “social determinants” of health. And as Gorakhpur has shown, it is always the poorest who face the brunt of poor health policies, management and financing.