Cathal McNaughton / Reuters
It was one of those moments that had the entire nation uniting in heartbreak and outrage, in equal measure. To see mothers grieving and hopeless, holding on to the lifeless bodies of their children, is something that can leave no one unmoved. As for the outrage—the situation could have easily been evaded. Millions expressed their angst and fury on social media, and every message made a similar point—this needs to stop.
For many of us, this tragedy brought with it an unpleasant sense of déjà vu. The faces of the distraught mothers might be different, but similar situations have been a regular occurrence. Each time, there is an outpouring of support and anger, followed by silence until the next incident rattles us out of our comfort zone. Why is it that even today millions of children in India are dying due to diseases, which are curable?
A total of 290 mothers lost their children at the BRD Medical College in Gorakhpur within a span of just one month. Out of the children who didn't make it, 213 were infants in the neonatal intensive care unit of the hospital. Other parts of the country are not immune to this scenario either. About 52 infants have breathed their last in a span of 30 days in Jamshedpur. As many as 660 children died at a hospital in Ranchi this year.
That we are not equipped to efficiently treat children in need of critical care is evident in the observations shared by every hospital—the children were admitted in serious condition. Even when the number of neonatal intensive care units and special newborn care units in the country has exponentially surged over the last few years, the number is still grossly inadequate and the gap in human power is daunting.
While the dearth of equipped neonatal care units with trained staff is a major reason for these deaths, the poor state of primary healthcare in India is also responsible.
The serious impact of lack of resources was evident in the BRD hospital tragedy. As the oxygen supply ran low, the hospital staff handed parents of the admitted children ambu bags to pump air into the lungs, due to the shortage of staff. Experts say that air pumped by ambu bags cannot replace oxygen, it can only replace a ventilator machine's bellows. It should be the job of a trained professional, with adequate skills to ensure correct bellows are given with correct pressure etc. This unmistakably points to the need for concrete efforts to expand in-service training programs and adopt innovative approaches.
While the dearth of equipped neonatal care units with trained staff is a major reason for these deaths, the poor state of primary healthcare in India is also responsible.
To understand what leads to this failure and child mortality we need to look at how the healthcare system is designed to work on the ground. The sub-centre (SC), which is the first point of contact between the primary healthcare system and the community, is designed to handle maternal and child health, disease control, and health counselling for a population of 3000 to 5000. The primary health centre (PHC) is the first point of contact between a village community and a doctor and provides curative and preventive services to 20,000 to 30,000 people. It serves as a referral unit for six sub-centres and has four to six beds for patients. Any child in need is referred to a PHC by an ASHA worker.
The community health centre (CHC) is the third tier of the network of rural healthcare institutions and provides specialist care to patients referred from primary health centres. CHCs are managed and maintained by state governments and are mandated to have four medical specialists, supported by 21 paramedical and other staff, with 30 beds, laboratory, X-ray, and other facilities. It covers 80,000 to 120,000 people.
The elaborate structure of the healthcare system is of little bearing if there is a severe shortage of staff and supplies.
The elaborate structure of the healthcare system, however, is of little bearing if there is a severe shortage of staff and supplies. In India there is a shortfall of 14%, 22% and 30% in the number of SCs, PHCs and CHCs respectively. Even within this inadequate set up, the shortfall of human resources is alarming, particularly in physicians and paediatricians; there is a shortfall of 80% or more in India of these specialisations. The situation is the same in the state of UP where the Gorakhpur tragedy has taken place. In UP, the PHCs, which serve as the first point of contact with a doctor, suffer from a shortfall of 37% in medical doctors. A staggering 31 million children in India are still not covered by these community health centres.
The objective of having a referral centre for the primary healthcare institutions was to make health services available, accessible and affordable to the rural people and to ease the overcrowding in the district hospitals. However, there are simply not enough centres and doctors to meet the demand and this is a reason for the high child mortality rate. Due to lack of public health provisioning, people end up going to quacks and reach hospitals only when the condition becomes critical. Clearly, with efficient and equitable health systems and doctors at the primary healthcare level, many of these deaths could easily have been averted.
Under the National Health Mission there is a provision to review and investigate the sequence of events leading to a child's death through death audits. This provision was introduced to gain valuable insights into identifying the cause of death. However, initial information for these audits is collected by ASHA workers who are not trained to investigate these causes. If prompt reporting and review of child deaths at every level by trained professionals is made a norm, it can provide useful information to assess the impact of the ongoing health programs and further assist in reducing the infant and child mortality rates.
Making health a fundamental right would give citizens the power to hold the state accountable for fulfilling its responsibility toward them.
Clearly, we need to develop a broader vision and a concrete plan of action if we are to avert further tragedies. We owe it to the 1.2 million children who die of preventable diseases before celebrating their fifth birthday.
It took us more than 25 years to bring down the infant mortality rates from 80 per 1000 live births in 1990 to 41 per 1000 live births in 2015. Let the wait for improvement not be so long.
Even though the right to health is not included as an explicit fundamental right in the Indian Constitution, the state is obliged to promote the welfare of the people. It is the state's duty to protect its citizens from mortality and morbidity caused by disease and illness. Without public health, public welfare remains impossible—thus, making health a fundamental right would give citizens the power to hold the state accountable for fulfilling its responsibility toward them.