Written by Anupama Ghosh*
In June 2016, Prime Minister Narendra Modi laid the foundation stone for the All India Institute of Medical Sciences (AIIMS) at Gorakhpur. Its foremost purpose is to provide affordable and quality tertiary-level healthcare to eastern Uttar Pradesh (UP), a region that has consistently struggled with poor and inadequate healthcare infrastructure. AIIMS is set to be functional in Gorakhpur by 2019 and is expected to take some strain off the BRD Medical College, where 296 children died in August this year. While 213 children who died were in the neo-natal ICU, 83 were in the encephalitis ward. These deaths call attention to the failure of the successive governments to tackle the encephalitis syndrome, which assumes epidemic proportions in UP each year. More importantly, they show that the issues related to healthcare are inherent to this region and the establishment of AIIMS might not be a viable solution.
Dismal Heath Indicators of Gorakhpur Children
The health indicators of the children in Gorakhpur are so dismal that they fare much worse than the state or national averages. Health experts state that under-nourished children with low immunity power are easy prey to diseases like encephalitis. A National Family Health Survey in the Gorakhpur division comprising the districts of Gorakhpur, Maharajganj, Kushinagar and Deoria reported more than one-third of children to be under-weight and two-thirds to be anaemic. While the Infant Mortality Rate (IMR) are 40 in India and 48 in UP, data from the health department put IMR in Gorakhpur at 62. Gorakhpur’s under-five mortality rate is also higher than the national and state averages. As per the Annual Health Survey (2012–13) report, Gorakhpur’s under-five mortality rate is 76, which is much higher than that of UP (62) and the national average (50). Estimates from the fourth National Family Health Survey found 42 per cent of children in Gorakhpur and 59 per cent in Deoria with stunted growth.
The fundamental reasons for the spike in the number of children falling fatally ill in the region are unsafe drinking water, unhygienic surroundings, incomplete immunisation and malnutrition. Encephalitis is a vector-borne disease that finds the moisture-laden topography of the region, especially in the monsoon season, to be highly conducive. According to the Swachh Bharat Survey (2017) conducted among 434 cities and towns in India, Gorakhpur ranked 314, while districts like Basti and Gonda in eastern UP ranked 386 and 434, respectively.
Inadequate Immunisation Coverage
Official figures put the death toll due to Acute Encephalitis Syndrome (AES) and Japanese Encephalitis (JE) at around 25,000 since 1978, with children below the age of 15 more prone to the diseases. AES and JE are viral diseases that are incurable, making their prevention the only possible cure. This makes vaccination critical, even though there is no concrete proof that it can successfully eradicate the disease.
In May 2017, the State Government started a vaccination campaign against JE in 38 districts of UP. Most of the districts in eastern UP like Gorakhpur, Deoria, Gonda, Basti, Ghazipur and Azamgarh were declared encephalitis-affected districts. However, mere immunisation campaigns are not enough for the containment of the disease. A survey conducted by the Indian Council of Medical Research (ICMR) between May and August 2015 found administering the required doses to all the children in the region as the biggest challenge. The survey covered 840 children in the major districts of the Gorakhpur division like Gorakhpur, Deoria, Kushinagar and Maharajganj. While two doses of JE vaccine were administered under the Universal Immunisation Programme, three of the four children aged 25–36 months in the division received only one dose of JE vaccine. The coverage of the two doses was, however, low. This inability to administer the required doses to the children in the encephalitis-affected districts makes the children vulnerable to the virus.
Inadequate Healthcare Centres
UP does not have adequate number of health centres at the local level in the form of Sub Centres (SCs), Primary Health Centres (PHCs) and Community Health Centres (CHCs). The functional centres are inadequately staffed, which means that there are fewer numbers of trained vaccinators to administer the correct dosage to all susceptible children. According to the National Health Mission (2016–17) report, Gorakhpur had only two district hospitals in 2014. The district had 529 SCs, 11 PHCs, 57 additional PHCs and 16 CHCs for an estimated 36.032 lakh rural population, according to the census figures of 2011.
It is no surprise that the number of paediatricians in the various CHCs in the region is less than the required number. While the two district hospitals in Gorakhpur had paediatricians, as per the District Level Household and Facility Survey (2012–13), only four of 23 CHCs in the district had paediatricians. The case was similar in the neighbouring districts of Kushinagar and Deoria. While only one of 16 CHCs in Kushinagar had paediatricians, four of 24 CHCs in Deoria had paediatricians.
The health centres across the state are plagued by irregular water and power supply. The District Level Household and Facility Survey (2012–13) found most of the SCs in Basti, Maharajganj, Kushinagar and Deoria in eastern UP having below state average water supply. While only 5 per cent of SCs functioning from government buildings in UP had regular electricity, the condition was more deplorable in the eastern part of the state. Nearly 90 per cent of PHCs in UP functioned without regular power supply and only 14 per cent of PHCs surveyed had a functional vehicle.
Data from a report by Brookings India, a health monitor that conducts research based on public health data, indicate a shortage of 37 per cent of health sub centres in Gorakhpur, where only 45 per cent of villages have access to SCs in a five-km radius. This makes BRD Medical College Gorakhpur a nodal point. Medical cases not only from the district but also from the neighbouring districts of eastern UP and Bihar are referred to BRD Medical College for treatment. According to a Comptroller and Auditor General (CAG) report of June 2017, BRD Gorakhpur faced a severe shortage of crucial equipment and trained staff. The report also states a shortage of 27.21 per cent of clinical equipment and 56.33 per cent of non-clinical equipment against the minimum requirement prescribed by the Medical Council of India.
In the backdrop of this tragedy, the Union Government has approved the setting up of a regional medical centre in Gorakhpur for an in-depth research into children’s diseases. The establishment of facilities like AIIMS and research centres is vital. However, the significance of health centres at the local level must not be ignored, as they are the first point of contact in many far-off districts.
Improper and insufficient immunisation programme that does not cover children susceptible to various diseases that have been ravaging the region for decades, inadequate healthcare centres and delays in payments for non-clinical equipment as critical as oxygen – the Gorakhpur tragedy is a grim reminder to all the aspects that make the healthcare system of the state dismal. It accentuates the general state apathy to providing quality healthcare to the people, especially children, who bear the brunt.
*Anupama Ghosh is Research Intern, CPPR
Views expressed in this article are personal and do not reflect those of CPPR.