Over 31 people died in Maharashtra's Nanded government hospital earlier this week. Just hours after the news of this tragedy broke out, reports came in from Aurangabad about 18 patients dying in the hospital. These incidents are not as uncommon as we would like to believe.
But we can’t know for sure. The National Health Profile acknowledges that only 28 percent of all registered deaths are medically certified. We don’t know much about the countless tragedies that occur with no record.
If you ask any aspiring PG doctors what the format of entering the cause of death is, they will tell you that the practitioner must mention both the immediate cause and the antecedent cause for death in the certificate.
But if you see a doctor in a ward writing a death certificate, they will tell you that they have the living to attend to.
And if you ask the kin of the deceased, they will likely tell you they are not sure why the person died.
In a heavily overworked healthcare system, doctors struggle to find a balance between documentation, provision of care, counselling of the patient’s kin and, to put it crudely, surviving.
The doctor is often blamed. It is not that doctors are guileless, they are humans after all.
But it is important to remember that doctors don’t (and shouldn’t) work alone.
So who is at fault?
The courts will likely provide an answer in due course. Many would have died by then. Say, we do find someone to blame. What then?
Will we be satisfied to say that doctors were heartless? Negligent? Cruel? Will it add to the ever-growing mistrust of healthcare workers? Will this incident be sensationalised to the point that the next time a doctor is beaten up, a small voice in our heads will say, “they deserve it”?
This is where we are. There is someone to blame and we move on.
Identify & Fill Gaps in the Healthcare System
The breakdown of trust between healthcare workers and patients – and the concurrent breakdown of the healthcare system – requires us to shake off the resignation to fate and to recover what we have lost and continue to lose.
There are conflicting reports of the shortage of drugs in the Nanded tragedy.
Ask any doctor who has ever worked in a government institution, we have seen shortages of several drugs ranging from antibiotics to saline drips.
Anyone who has visited a government hospital will tell you that you have to buy at least some of the drugs in order to facilitate treatment.
This is especially jarring if you think of the usual visitors to government hospitals – the less privileged sections of society.
Despite the advent of Ayushman Bharat, people have to spend out of pocket in order to ensure care for their loved ones.
How can providing coverage for the cost of medication work if the medicine does not exist in the hospitals?
What does a person do with coverage if they have to keep depending on procuring therapeutic drugs from outside the hospital?
The unavailability of drugs does not only affect the out-of-pocket expenditure but can also cause delay in treatments which, in some cases, can prove fatal.
Hospital administration might tell you this is an indenting problem, the ward in-charge could tell you it is a corruption problem, and it possibly could be both – but more importantly this is a life and death situation.
When the current tragedy happened in a “750-bedded tertiary-level hospital & teaching institution with an excellent facility of modern equipment,” we can only imagine what happens in the centres that can’t boast of the same.
A disaster management cycle tells you that while you respond and recover from a disaster you must move towards adaptation and preparedness.
Even as we circle around possible perpetrators of a crime, we forget to find ways to prepare and prevent further events like this.
We are hearing of several drug shortages in the country since last year, from TB medication to medicines for HIV.
We have seen several people with chronic conditions struggle to find drugs that they need to survive.
Do we wait for this to escalate into news of mortality before we act upon it?
Due to the obsession with finding a culprit, we are afraid to identify gaps in the system. The gaps that don’t get identified cannot get filled – the death of 31 people in 48 hours is one such example that we know of.
Putting Redressal Mechanisms in Place: How Can it be Done?
One way of addressing such tragedies is to use quality improvement strategies. This would mean:
Shifting focus from finding blame in one person to working together as a team.
It would also mean putting mechanisms in place to adapt to situations as per the local situation.
In the ongoing efforts at quality assurance, there are books worth of checklists to ensure quality.
Though perhaps well-intentioned, these are highly centralised and only feed back into the existing medical hierarchies.
If a nursing staff identifies a problem in the functioning of a ward, she is unlikely to have the power to suggest and enact changes even in her particular ward.
Medical death review meetings also tend to strengthen such hierarchies. And they also end up becoming another mechanical burden of documentation rather than a space to solve and ideally, prevent future problems. What we should also be asking is:
Who is present in the meeting?
Do the kin ever learn of the causes and outcomes?
Is this knowledge considered the kin's right, irrespective of their ability to pay, read, or present their case in a polished manner?
The reports pouring in suggest a cruel alienation of the family such that their grief is left not only unaddressed but also, invalidated.
Doctors cannot and should not be responsible for healthcare all alone. Ensuring the availability of drugs is not in a single person’s hands. Inventory is not a one-time thing.
The value of the life of an underprivileged person getting admitted to a government hospital hasn’t been systemically diminished in a day.
Health, much like life, is a messy business and if we are to improve it, we must create space for identification of gaps without the fear of being scapegoated.
We must restore value to the entire health team, including the politician, the hospital admin, the patient, and the kin who are an integral part to the healing process.
In situations where death becomes inevitable, it is important to be transparent with the patient and their family to ensure space to grieve.
To provide such a space, healthcare workers must also be allowed to be human – a sleep-deprived person is unlikely to be high on empathy.
None of these issues exist in a silo. Hence, they cannot be addressed in a silo.
There are no straight answers, the questions are many. That does not mean we stop asking them. Even as elections loom, these questions are essential to ask. After all, as Rudolf Virchow put it more than a century ago,
“Medicine is a social science, and politics is nothing more than medicine on a grand scale."
(Dr Shivangi Shankar is a medical doctor and public health researcher. This is an opinion article and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for them.)