While the children’s families blame the staff of Kota’s J.K. Lon Hospital for negligence, studies show that the government hospital is poorly equipped and understaffed. Mohammed Iqbal reports on the failure of the primary healthcare system which has led to the deaths of more than a hundred children in the last 40 days
When four-month-old Tejas had a constant cough, ran a high fever and experienced shortness of breath in November 2019, his worried parents rushed him to a neighbourhood doctor. Suspecting pneumonia, the doctor advised the parents to hospitalise Tejas immediately. Sanjay and Padma Rawal took the infant to J.K. Lon Mother and Child Hospital, a government-run children’s healthcare centre. With 307 beds, it is the largest hospital in Kota, Rajasthan.
Though Tejas showed some improvement, Rawal, 30, who works at the Krishi Upaj Mandi, the local agricultural marketing hub, was not satisfied. Tejas’ fever had not subsided and Rawal felt that the doctors were not giving him sufficient attention. The family shifted the infant to a private hospital after three days though they knew that in all probability they could ill afford treatment there.
Rawal sold his wife’s jewellery for ₹80,000 to meet the cost of treatment for 10 days. Extensive tests, including a chest X-ray, blood tests and sonography, were conducted. Medicines and injections were given. Tejas was discharged after the doctors assured his parents that he had fully recovered.
However, on December 22, Tejas experienced sudden breathlessness again. Accompanied by his wife and parents, Rawal, who had no money left to take his son to a private hospital again, rushed him once more to J.K. Lon Hospital’s emergency ward. Though the infant was stable on the first day, his condition deteriorated the next day. His stomach swelled up and he was taken to the intensive care unit.
Tejas died of pneumonia on the evening of December 23. A pall of gloom descended on the modest house of the Rawals in the Chhatrapura locality of Kota, where the joint family has been living for two decades. Rawal had already lost his eldest son, Devesh, in 2012, when the child was only one-and-a-half-months old. Rawal has two daughters: one aged six years and the other, four.
In one month, a hundred children
Tejas was among the 10 infants who died in J.K. Lon Hospital on December 23 and 24. News of the children’s deaths and the abysmal state of the government hospital sparked a nationwide furore. The deaths of 100 children in the hospital in December alone followed by more deaths in the first week of 2020 has brought a renewed focus on the country’s maternal and child health care system.
Tejas’ mother Padma says her son died due to the negligence of the doctors and nursing staff in the hospital. “He developed mouth ulcers after being admitted and would not drink milk. The nurses put the drip but forgot to take it out. Once there was blood in the drip. The doctors only attended to my son when his stomach swelled up, but it was too late by then,” she says, barely controlling her tears.
Asim Hussain and his wife Rukhsar Bano of Satish Vihar locality in Kota lost their first-born three days before their marriage anniversary. Their daughter was put on a ventilator when she developed fever and faced difficulty in breathing just 14 days after her birth on December 15. When she lost her life, the doctors were unable to explain why the artificial respiration system did not work for her, the parents say.
Shubham Hada, who brought his infant of two days with a respiratory disorder to the hospital’s ICU in mid-December, says there were no window panes near the child’s bed. The infant was exposed to the biting cold at night and died of hypothermia two days later.
On January 6, the relatives of a couple from Bhilwara district’s Mandalgarh town staged a dharna at the gate of J.K. Lon Hospital, carrying the body of a three-day-old girl who was born via C-section. The child had been shifted to the ICU after the nose drops given to her when she was crying apparently caused breathlessness. The relatives allege that the doctors did not treat her properly and that the paramedical staff were mostly busy on their mobile phones.
The hospital’s Medical Superintendent, Suresh Chand Dulara, met the agitators and assured them of prompt action. He said the hospital would ensure regular visits of paediatricians to the maternity ward and plug the loopholes in the ICU. The baby’s father, Shakir Mohammed, who was earlier demanding police intervention in the matter, handed over a written complaint to the hospital administration about the appalling facilities.
Poor facilities, overworked staff
When the shockingly high number of infant deaths in Kota came to light, the Congress government in Rajasthan swung into action. It sent a team of paediatricians from Jaipur to look into the causes of mortality. The team found that the five boys and five girls who died on December 23 and 24 had been suffering from birth asphyxia, septicaemia, aspiration pneumonia and convulsions.
The J.K. Lon Hospital, which also ordered an investigation into the children’s deaths, initially maintained that the infant mortality rate had been gradually coming down over the years in the institution. The hospital’s neonatal ICU ranking, issued by the National Health Mission on a monthly basis by assessing the quality of services, also consistently showed a low infant mortality rate.
However, patients and others visiting the hospital say that it is extremely unhygienic and filthy, with even pigs straying into the premises sometimes.
Ever since news of the deaths hit the headlines and Ministers started visiting the hospital, J.K. Lon has taken up renovation work on a large scale. It has placed fibre sheets and curtains on open windows, painted the walls, repaired the gates, and replaced the broken furniture. A proposal has been moved for the construction of three new wards with a capacity of 156 beds. A new neonatal ICU with 12 beds is expected to start functioning within a fortnight.
Dr. Amrit Lal Bairwa, who heads the Paediatrics Department at J.K. Lon Hospital, says it would be wrong to attribute the deaths of the infants to the negligence of doctors or the paramedical staff. “As the biggest hospital in the region, this is a tertiary care medical facility. The children are mostly referred to us by private hospitals in the nearby districts and many of them come when they are at the terminal stage of their illness,” he says. Bairwa says infants who come from private hospitals develop hypothermia, hypoglycemia and hypoxia during transit. “By the time they get here, they are in a serious condition. We get only 24-48 hours to save them. Often we are helpless.”
While admitting that there is a shortage of staff, Bairwa says the overworked resident doctors, paediatricians and nurses all work to provide the best medical care to children. He points out that about 60% of the children dying during treatment are male, as boys are more susceptible to septicaemia and other infections.
According to data of the hospital administration, against the death of 100 children in December 2019 and 101 in November 2019, 77 infants lost their lives in December 2018 and 76 in November 2018. By the end of the first week of 2020, a dozen more children had lost their lives following health complications.
An internal study by J.K. Lon Hospital has found that it needs at least 300 more beds to cater to the child population of the Hadoti region, comprising Kota, Baran, Bundi and Jhalawar districts. Medical Superintendent Dulara says the existing resources and infrastructure are being strengthened. The Public Works Department estimates an expenditure of ₹1.35 crore for repairing the hospital building and undertaking other works.
A major shortcoming in the hospital is the absence of a centralised oxygen system, as the oxygen cylinders are supplied by carts. Besides, Chinese medical equipment of inferior quality is being used for treatment, putting the children’s health at risk. Minister of Health and Family Welfare Raghu Sharma has since ordered a probe to find out why Chinese equipment was purchased in Kota.
A report by the Paediatrics Department has also stated that 13 out of the 19 ventilators in the hospital were defunct, 81 of the 111 infusion pumps were useless, and 44 of the 71 warmers were not working. Most of the nebulisers, which are required especially during winter, were also defunct. Against the 12 sanctioned posts of professors and associate professors, only seven are working.
In the midst of the outrage caused by the death of infants in Kota, disturbing figures of similar deaths emerged from Jodhpur and Bikaner as well as Gujarat’s Rajkot and Ahmedabad. A joint report on infant deaths in Jodhpur’s Umaid Hospital and M.D.M. Hospital revealed that 146 deaths were recorded at their neonatal ICU and paediatric ICU in December 2019. The number of deaths in Bikaner’s P.B.M. Hospital surpassed those in Kota, with 162 deaths reported in December alone.
Political blame game
The Kota episode, followed by deaths reported from elsewhere, has not only put the focus on the public health scenario in the State, but also unleashed a political blame game between the ruling Congress government and the Opposition. Chief Minister Ashok Gehlot was criticised for his remarks that some “mischievous elements” were highlighting the issue to divert attention from other subjects. Gehlot claimed that his government had brought down the number of casualties compared to those reported in the previous years. “Despite consistent improvement in survival numbers, we still have a thousand deaths every year, with many other hospitals having a similar rate. This is because of the overall high mortality rate for newborns in Rajasthan,” he said.
The BJP took up the issue at the Central level, with Kota MP and Lok Sabha Speaker Om Birla holding a review meeting with Union Health Minister Harsh Vardhan on the matter. Bahujan Samaj Party president Mayawati and Uttar Pradesh Chief Minister Yogi Adityanath questioned the silence of senior Congress leaders over the deaths.
The Union Health Ministry sent a high-level team comprising experts from AIIMS, Jodhpur, and health economists to Kota to assess the infrastructural gaps and decide on the measures to be taken to prevent further deaths. The team carried out an analysis of clinical protocols, service delivery and availability of manpower and equipment at the hospital.
Gehlot asked Harsh Vardhan to visit J.K. Lon Hospital and see the “best of facilities and proper management” in order to get himself apprised of the facts. “Harsh Vardhan Ji is himself a doctor and if he visits the hospital in #Kota, it will also clarify the situation for people, who are giving [their] reaction mischievously, knowingly, unknowingly and also innocently,” he tweeted.
Deputy Chief Minister Sachin Pilot, who is also the Pradesh Congress Committee president, created a flutter by describing the deaths as “a heart-wrenching matter” and called for fixing accountability for the episode. He said it would serve no purpose to blame the previous BJP regime given that the Congress has been in power in the State for the last 13 months.
After visiting the hospital, Pilot told reporters in Kota that the State government’s response to the continuing deaths should have been “more sensitive”. “Our response was not satisfactory to some extent. We should have been more compassionate… Since we are in power, we have to be responsible and face consequences,” said Pilot, who also met some of the families who had lost their children.
Pressure on tertiary health care
With the emphasis on public health and nutrition infrastructure, activists working in the field of health care and the right to health feel that the issue of infant deaths in Kota should not be seen in isolation. “It is a sheer manifestation of the collapse of the public health system at all levels. Unless our outreach maternal health services, child health services and primary health care facilities are strengthened, we cannot expect lives to be saved only through treatment at the tertiary level,” health activist Chhaya Pachauli says.
Pachauli, senior programme coordinator with Prayas and affiliated to the Rajasthan Jan Swasthya Abhiyan, says there is an urgent need to increase health and nutrition budgets, which are abysmally low, in order to get the mandated outcome from healthcare facilities. “We need to reduce the patient load at the tertiary level. Tertiary health care is catering to a much higher number of patients than what it is meant to cater to, while primary care facilities are grossly underutilised… It is a matter of revamping the entire public health system from bottom to up.”
Low budget, unutilised funds
Figures from the National Family Health Survey depict a gradual decline in both infant and maternal mortality, but the pace has not been satisfactory. Against the national average of 33 infant deaths per 1,000 live births, the infant mortality rate in Rajasthan is 38, as per the latest Sample Registration System Bulletin. The infant mortality rate in the State was 41 in the previous Sample Registration System.
Nesar Ahmad, Director of the Jaipur-based Budget Analysis amd Research Centre Trust, says infant mortality is a consequence of poor budgetary allocation for medical and public health combined with the problem of unspent capital funds. The capital expenditure budget has not only declined from ₹1,073 crore in 2014-15 to ₹789 crore in 2019-20, only about half of it has been utilised over the years.
“Even in 2017-18, when the utilisation rate of the health budget was 100% in Rajasthan, the capital account budget was underutilised by 50%,” Ahmad says. He adds that this obviously impacts infrastructure and maintenance of medical equipment in government-run hospitals.
The State budget estimate data show that allocation for health and family welfare increased by an abysmal 1.76% between 2018-19 and 2019-20, against a 9.61% increase in the total budget. Ahmad says the previous government had laid undue focus on privatisation of health services and promoted the Bhamashah health insurance scheme, which entailed cashless treatment at empanelled private hospitals, at the cost of other schemes to provide primary health care to all.
The health budget in the State hovers at about 6% of the total Budget. Besides, the budget for the centrally sponsored National Health Mission has been declining since 2015-16. The National Health Mission budget in the current year is ₹2,101 crore, which is still lower than the ₹2,120 crore sanctioned in 2014-15.
All these figures mean little to the families who have lost their babies. Lala Ram, whose five-month-old daughter, referred from Bundi, died a day after the visit of the State’s Health Minister, says the infant could not survive because of the “collective failure” of the hospital’s staff and infrastructure. “Very little will change unless an element of empathy is brought in here. They too have children, they should feel our pain,” Lala Ram says.
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