No country for the ill

The inability to ensure long-term behavioural changes among both people and the health care sector is reflected in repeated outbreaks of epidemics

Avinash Rout was just seven years old and Aman Sharma only six, but these children have, in death, left a State government and the country with a lot of disturbing questions.

It is heartbreaking that Avinash’s parents are also no longer around to witness this unfolding drama. Taken from one hospital to another over a full 24 hours (Moolchand, Max Saket, Saket City, Aakash and Irene Hospitals), this very young child, sick with dengue, breathed his last at Batra Hospital. The young, broken parents jumped to their deaths, seeing no reason to live after having failed to ensure their little one a chance at life. Aman, meanwhile, died at the Holy Family Hospital in the capital, again after several hospital rounds apparently.

Despite crores of rupees spent and several policies and programme initiatives, Avinash and his parents in the heart of posh southern Delhi had no place to go to for treatment.

Unacceptable complacency

This is totally unacceptable and the Avinash Rout case will go down in the history of health care in India. I am sure the incident will continue to steal the peace and complacency of countless health professionals — whether many of them admit it — and managers in this country where we seem better at marketing cell phones and tablets rather than setting right an ailing health system, ridden with what were earlier just inadequacies and inefficiencies, but are now unpardonable and gargantuan errors. Reform is imperative, or else a revolution.

More than 15 years ago, when dengue first showed up in a virulent form in Delhi and claimed many lives, a slew of prevention and control measures were discussed, debated and even implemented. But we have short memories and it takes very little to push people back into old behaviour patterns that time and again cause the same epidemics. This is really a behaviour issue, whether of the beneficiary of the health and civic system, or the providers of the same. None of the basic practices of cleanliness — at multiple levels of the individual, community and civic administration, to prevent the breeding of the city-slicker, day-time Aedes aegypti mosquito, using simple techniques to protect oneself from being bitten — seems to have become ingrained behaviour.

Court directive

The refusal by medical facilities to admit critically ill patients is also a behavioural issue, not supported by guidelines and protocol. More than a quarter of a century ago, in 1989, through the case of Parmanand Katara Vs the Union of India , the Supreme Court passed a landmark judgment that no medical facility can refuse or turn away any critically ill or emergency patient, on any grounds. It unambiguously stated that such refusal would be viewed as a violation of the right to health, enshrined within Article 21 of the Constitution that guarantees the right to life and liberty.

It is the state’s obligation to preserve life and provide timely medical treatment, overriding the professional freedom to refuse a patient. “Every doctor, whether at a government hospital or otherwise, has the professional obligation to extend his services with due expertise for protecting life”. But the Routs were turned away, not once, not twice, but a full five times.

The Indian health care system needs simple, managerial reform that can no longer be denied to the people. For example, how a first-point-of-contact institution, whether private or public, a small clinic or a large hospital, responds when a person is brought in clinical distress is critical. Equally crucial is monitoring the quality and robustness of that response. Who’s watching, is the question and who is accountable for the failures in health service delivery? That, undoubtedly, is the elephant in the room.

Neighbouring Sri Lanka, always known for its progressive and highly successful public health services and initiatives, has seen enormous success with its anti-malaria campaign despite nearly three decades of separatist unrest and war. In fact, Sri Lanka is considered almost malaria-free because of enormous efforts focussed on the health system, communities, human resources and various other aspects of a public infrastructure.

Inefficiency of civic bodies

In India, meanwhile, even something as basic as cleanliness and hygiene — the political flavour of the season — shows up the dire inefficiency of civic bodies. Prime Minister Narendra Modi’s Swachch Bharat is right now a pipe dream, and the 150th birth anniversary of Mahatma Gandhi may well go past without the promised gift of a clean India. Again, the barriers are managerial and behavioural.

Meanwhile, is it difficult for ordinary people to challenge and question the kind of medical attention they receive at the best of times. The regulation of medical practice is a fraught issue and has been so for years. Although the Consumer Protection Act is applicable to health services, and there is now the Clinical Establishments (Registration and Regulation) Act of 2010, the need to access emergency health care is always of such urgency, and characterised by extreme emotional upheaval, that human vulnerability takes over. Also, medical care is highly technical and skilled, making greater the vulnerability of those in distress.

So why was Avinash turned away by five hospitals? Was it really a lack of beds? Was it fear of medico-legal consequences of a critically ill patient? Or was it genuine inability to treat the condition due to lack of appropriate equipment or medical skills? Somebody has to be held accountable for the death of Avinash, and in reflected anguish, that of his parents. Meanwhile, the National Health Bill has remained a Bill. Such a pity.

(Dr. Subhadra Menon is professor, Health Communication, The Public Health Foundation of India and author of No Place to Go: Stories of Hope and Despair from India’s Ailing Health Sector .)