public healthcare

In one Jharkhand hospital, too many patients, too few doctors and a large number of child deaths

India has always had too many avoidable child deaths. Most are due to overburdened hospitals and medical staff.

The hospital ward was teeming during lunch hour. Several children, undergoing treatment, ate rice and dal from styrofoam plates, seated on hospital beds covered with green bedsheets. A few children, attended by their families, rested on mattresses on the floor lined along the hospital corridor. This was the only space where they had found space to receive treatment at the paediatrics department of Rajendra Institute of Medical Sciences or RIMS in Ranchi, Jharkhand’s largest public hospital and medical college.

Shafiq Ansari sat on one such floor bed with balloons painted on a peeling wall behind him, waiting with his son Mujahid, a 10-year-old boy with large eyes and a shy demeanor. Mujahid has lived with sickle cell anaemia, a blood disorder, since he was four.

Last week, just days after reports that 70 children had died in Gorakhpur’s Baba Raghav Das Medical College and public hospital in August, news reports highlighted a slew of deaths in Jharkhand’s public hospitals during the same period. The National Human Rights Commission and the Jharkhand High Court have issued show cause notices to the state government. On August 27, the news agency ANI reported that 52 infants had died in 30 days in Jamshedpur’s Mahatma Gandhi Memorial Medical College and Hospital. Over 28 days in August, 133 children died in the paediatric ward of RIMS, where Ansari waited.

Despite the new scrutiny on the high number of deaths among children admitted to the hospital, Ansari had arrived there as usual from his village Karwadih in Garhwa, traveling 250 kilometers to get his son Mujahid admitted, as he does twice every year.

“The staff at the district hospital at Garhwa did nothing to help when I first took Mujahid there,” he said. “So, I brought him to RIMS for treatment. I bring him here every six months, he is better after the visits.”

It was the second day since the hospital admission. Mujahid would receive medicines through an intravenous drip while he stayed on a mattress on the floor of the hospital the next eight days.

Three-year old Ibram has nephrotic syndrome, disease in which protein is lost through the kidneys, resulting in low blood protein levels and in water being drawn in tissues resulting in swelling. Ibram is severely underweight, and had been undergoing treatment for a week. His grandmother Jaina Bibi said the family came to RIMS after spending Rs 1.5 lakh for his treatment at a private hospital for 15 months during which Ibram showed little improvement. The fees at the private hospital were very steep Ibram’s father who works as a painter. At RIMS, the family spent Rs 100 everyday for two bottles of intravenous fluid bottles, though the hospital is supposed to provide this free of cost.
Three-year old Ibram has nephrotic syndrome, disease in which protein is lost through the kidneys, resulting in low blood protein levels and in water being drawn in tissues resulting in swelling. Ibram is severely underweight, and had been undergoing treatment for a week. His grandmother Jaina Bibi said the family came to RIMS after spending Rs 1.5 lakh for his treatment at a private hospital for 15 months during which Ibram showed little improvement. The fees at the private hospital were very steep Ibram’s father who works as a painter. At RIMS, the family spent Rs 100 everyday for two bottles of intravenous fluid bottles, though the hospital is supposed to provide this free of cost.

High mortality

In 2002, two years after Jharkhand state was carved out of Bihar, the Ranchi Medical College was upgraded to become RIMS. The institute is an autonomous body and the largest multi-speciality public hospital in the state, with 1,500 beds, nearly three times as big as the state’s second largest public hospital in Jamshedpur.

The hospital administration termed the news reports of a spike in deaths “exaggerated” and “false.” Among 3,324 children admitted in the general ward this year, 268 have died. The hospital administration also released data to show that 24% of the fatalities were due to encephalopathy, a broad term for any disease that causes brain damage or malfunction, which could be caused by malaria, scrub typhus, encephalitis, or other infections. Encephalopathy is a serious medical condition with a high mortality rate. Pneumonia was the second biggest cause, causing 17% of the deaths, said officials.

Dr AK Chaudhary, who is head of department, paediatrics ward at RIMS, said there had been no spike in encephalitis deaths at the ward.

“We have shown that most deaths occurred within 24 hours of admission, showing the severity of illness, in which the hospital could not have done much,” he said.

Of 4,855 infants and children admitted in all wards between January 1 and August 28, 660 died. Professor (Dr) BL Sherwal, the director and administrative head of RIMS, said these records for all infants and children’s wards, for both general and intensive care, showed a mortality of 13.5% which was “similar to last year”. Sherwal declined to share or publish the data on mortality in the paediatrics ward over the past year, or the previous years’ figures, which would allow comparison between this year’s mortality versus earlier.

The paediatrics ward has 146 beds in the general ward, and 46 beds in intensive care units, including neo-natal care. The department receives two to three times that number of patients seeking treatment, said the doctors.

Senior doctors admitted that a ratio of two children or infants to one bed in the general ward and even in intensive care was common, and had not improved in more than a decade.

Other senior doctors also defended themselves against the criticism over high mortality, and denied any negligence. “Private doctors send off their patients here when they cannot be saved, even then, we save 85% of the children who come here,” said a senior associate professor of pediatrics Dr A Verma who has worked in the same ward since 22 years. “We do not refuse anyone who comes to us.” he said.

A few minutes later, as a teenaged juvenile diabetic patient arrived to consult the doctor, he advised the family to stay three more days in a rented quarter outside the hospital till her treatment was over. “She is too susceptible to infection, there is no space for keeping her safe from infections here,” he said, after the family had left.

Newborns most vulnerable

Besides the overcrowding on the pediatrics ward floor, there is a severe shortage of space apparent even in the neonatal intensive care unit or NICU, for infants below 28 days. Inside the eight-bed special facility for newborns, up to four babies are sometimes admitted on one bed, and two to three babies are treated at the same time in phototherapy and warmer units, said the nursing staff. This works at cross purposes of providing intensive care as it heightens the chances of cross infection, say medical experts.

A nurse working at the ward said that often because of shortage of beds and facilities, one oxygen unit had to be used to provide treatment to three newborns at once, instead of one oxygen cylinder per crib.

Families wait at the NICU at RIMS, Ranchi after news of deaths nine babies who were discharged from this ward.
Families wait at the NICU at RIMS, Ranchi after news of deaths nine babies who were discharged from this ward.

After news of the high mortality in the paediatrics ward broke, while the patients in the general ward had continued as before, there was some panic at the neonatal care units. “After the news started coming out on babies’ deaths, the doctors discharged all the newborns who were stable to reduce overcrowding in the ICU,” said a nursing staff who declined to be identified. “Three families requested leave and took their infants somewhere else. We transferred three other babies to different units to further reduce overcrowding in ICU.”

Government of India’s Facility-Based Operational Newborn Care guidelines prescribe that a 12-bed Special Neonatal Care Unit requires at least 3 to 4 doctors, including a neonatal specialist, and three nurses in each shift.

The paediatrics department at RIMS has 46 beds in Intensive Care Units, including a 24-bed Special Neonatal Care Unit, and an 8-bedded NICU. It has four doctors, and six senior residents – which is half of the required doctors – and six nursing staff. It lacks a neonatal specialist.

RIMS director Sherwal, who is set to soon join a public hospital in Delhi, said that the hospital was not able to fill vacant posts. “Here, it is not like large metros where you advertise one post, and receive many job applications. If we advertise for 60 posts, we receive applications from just 20 candidates,” he said. “For the paediatrics department, we advertised three posts in August, of two senior residents and one registrar in neonatology, but no one applied for the posts.”

Besides, there has been no regular recruitment of doctors across the state. Since the creation of the state, the permanent recruitment of doctors through Jharkhand Public Service Commission has been done only in 2009, 2012, and 2015.

A senior paediatrician who has worked at Delhi’s Kalawati Saran Children’s Hospital, one of the largest hospitals for children in India, said that though there were no norms on mortality rate for a hospital, units working well usually saw a mortality of less than 5%, which could be slightly higher in intensive care units. “In one paediatric ward in another government hospital in Delhi, where the nursery was poorly managed, the death rate among admitted newborns was as high as 40%,” said the paediatrician who did not want to be identified. “With improved management, it fell down to less than 10%.”

Child deaths in India’s hospitals

The story of too many patients, under-equipped doctors and large number of child deaths plays out in government hospitals in other parts of the country. On September 4, media outlets reported that 49 children had died at a hospital in Farrukhabad district in Uttar Pradesh over one month. The news reports drew parallels to 63 deaths at a Gorakhpur hospital in mid-August. In both cases, references were made to “lack of oxygen” being investigated as the cause of death.

However, the two cases are markedly different. For starters, the deaths at the Baba Raghav Das Medical College and Hospital in Gorakhpur grabbed national attention because 23 children died in the neonatal and paediatric ICUs in a single day. Forty more children died over the next five days. The deaths coincided with reports that the hospital had failed to pay its dues to the company providing liquid oxygen needed in trauma and intensive care units and that the company had threatened to cut off supply.

At the Ram Manohar Lohia district hospital in Farrukhabad, 49 deaths have occurred over an entire month – that is, between July 20 and August 21. Of these, 19 infants were stillborn, implying that these deaths had little to do with hospital facilities for neonates and more with the health and nutritional status of their mothers. Doctors at the hospital said that 21 of the 30 children who died in the newborn care unit suffered from birth asphyxia, a condition where the baby is deprived of oxygen at, or around, the time of birth. This suggests that, unlike in Gorakhpur where an oxygen disruption was suspected to have played a role in the deaths, there was no interruption of oxygen supply at the Farrukhabad hospital.

Staff at the Farrukhabad hospital also resort to keeping more than one child in a bed and treating two or three children with the same oxygen cylinders at a time. The district hospital, which is a referral health facility, received 145 children in “critical condition” from different private and public hospitals in the region. In the 12-bed ward, 211 children had been treated over the month, of which 30 succumbed to various medical complications.

Such deaths may not be the result of a single event of failure or negligence by doctors but more often the result of an overall failure of the public health system.

Nearly 150 patients come to the outpatient department of RIMS everyday. Several families come to the hospital from Purulia in West Bengal, 150 kilometers away. They usually arrive at the hospital at midnight on Friday after traveling by train.
Nearly 150 patients come to the outpatient department of RIMS everyday. Several families come to the hospital from Purulia in West Bengal, 150 kilometers away. They usually arrive at the hospital at midnight on Friday after traveling by train.

“It is difficult to parse the data shared publicly by the hospital to establish one cause for the deaths, but the numbers also reflect the chronic excess demand on a failed public health system,” said Dr Yogesh Jain, a member of the non-profit Jan Swasthya Sahyog in Chhattisgarh. “If there is an emergency it can be understood, but how can we accept that there have been two to three patients per bed for over a decade? Why is there a chronic deprivation of public hospital care?” he asked.

Lindsay Barnes, who has worked with Jan Chetna Manch providing neonatal care in Chandankyari a rural area in Bokaro since over 15 years, said that it was not just a problem of lack of oxygen facilities. “Even if babies have low birth weight or difficulty breathing, complications could be prevented by resuscitation, regular feeding, and very clean, attentive nursing care which the newborns are not getting in these facilities.”

With input by Priyanka Vora. All photos by Anumeha Yadav.

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This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.