Outrage is a natural reaction to the terrible tragedy that cruelly crushed the lives of many innocent children in Gorakhpur. However, outrage is a wasted emotion if it is not accompanied by honest introspection to identify all contributory causes and followed by a cluster of corrective actions.
The deaths of these children were caused by the cumulative effect of multiple failures of the public health system and skewed developmental processes that inflict innumerable injuries of economic and social inequity on the poor. Life-threatening illness is created by social conditions that make children vulnerable to the assault of infectious agents that thrive in insanitary conditions. When they reach the overcrowded hospital in a desperately ill condition, an uncaring system fails to provide the critical care they need. These causes are not listed on a death certificate but are indeed the unnamed assassins that routinely and remorselessly kill children in large numbers in the underdeveloped and poorly served regions of our country.
Why does eastern Uttar Pradesh have very high levels of infant mortality, low birth weight and stunting compared to the national average? Why is Gorakhpur ranked so low in comparative rankings of urban cleanliness? Why are both the medical college and a large hospital managed by the same doctor who also has to sign off on bills of payment? Why are government doctors allowed to run private clinics? Why is there no electronic inventory of drugs and essential supplies to permit real time monitoring and prevent unforeseen stock-outs? How transparent or opaque is the procurement process? Why were numerous complaints from the vendor unheeded? These questions call for review and reform of a system ridden with faults at multiple levels.
What erupted as a breaking media story on August 11 was only the acute manifestation of the chronic malady that ails our health system. It is not a one-off event that resulted from a callous cut-off of oxygen supply by a rogue supplier. Even that despicable act is now shrouded in conflicting claims of who is to blame and contestation of whether or not the interruption of oxygen supply was a cause of death. The underlying disease is always the recorded primary cause of death but lack of respiratory support in a critically ill state can decrease the chance of recovery and hasten death. It is a contributory cause, just as inexcusable as non-availability of blood for life-saving transfusion when a road trauma victim reaches a hospital. If we now deviously dispute whether oxygen is even essential for the intensive care of comatose children with encephalitis or severe pneumonia, we will fail to ensure that such stock-outs will not happen ever again.
We do, however, need to look beyond the oxygen story. Early marriage and motherhood of an undernourished adolescent, leading to a low birth weight baby that suffers further malnutrition and falls easy prey to infections — this is the tale that plays out as the backdrop for sick children in hospitals in Gorakhpur and neighbouring districts. As mosquitos breed in paddy fields and pigs gorge on garbage piles near human dwellings, conditions are ripe for animal to human transmission of viruses through insect vectors. Bacteria, too, abound in unhygienic surroundings and easily invade the ill-nourished bodies of poor children. It requires an all-round development effort to alleviate poverty, ameliorate child nutrition and obliterate squalor. Even as we do this, we need to fix our dysfunctional health system.
Our disease surveillance system needs to be strengthened in both community and hospital settings, to provide reliable real-time data. Given the rising threat of zoonotic diseases that spread from animal to humans, eco-surveillance systems need to be developed for integrating data from wildlife, veterinary and human populations. Immunisation for vaccine preventable diseases, as recommended by the public health authorities, must be effectively delivered by the health workers after gaining community acceptance through culturally sensitive vaccine literacy programmes. The primary healthcare system must be well resourced and adequately staffed, to be capable of early detection and care, appropriate referral for advanced care when needed, and post-recovery counselling and follow-up. Fully functioning health and wellness sub-centres and primary health centres must speedily spring and serve close to the communities rather than rest and rust as undelivered plans in the proposals of health programmes. In cases with disabling sequelae, as in severe encephalitis, rehabilitation services too need to be accessible and efficient.
At the level of the district and medical college hospitals, where advanced care is provided, standard management protocols for clinical care and standard operating procedures for administrative processes are essential for ensuring timely, appropriate and empathetic care. Implementation of a programme of universal health coverage will also make it affordable. Transparent and dependable procurement systems, developed first in Tamil Nadu, will ensure uninterrupted availability of essential drugs and other supplies. Government doctors must be well paid but barred from private practice. Clinical competence must be supported by public health and management expertise.
Periodic quality audits must encompass technical, administrative and social audits. To make this happen, we need to invest in training and deploying professionals in public health management at different levels of the system. Based on a core combination of public health expertise and management skills, further specialisation can be customised for public health programme management and hospital management. While the National Health Policy of 2017 calls for the establishment of public health management cadres in every state, the need was never before as evident as now.
The children of Gorakhpur would not have died in vain if we can put aside political bickering and unitedly resolve to salvage and strengthen our sinking health system.