Genocide of infants in Niloufer Hospital
Vanam Jwala Narasimha Rao
National Information Services
Daily admissions here are anywhere between 200 and 250. Occupancy of beds is double the sanctioned bed strength. Nursing staff to take care of these in-patients are negligible in number. There is absolutely total absence of physical and ethical working conditions and conditions of work resulting in doctors' helplessness to adhere to ‘Hippocratic Oath’. Doctors' are caught with the dilemma whether to attend on 50:50 life saving chances infants or 90:10 chances infants. There is acute scarcity or meager supply of ventilators, monitors, infusion pumps, emergency drugs and no provision for emergency investigations like blood gas analysis, electrolytes, liver functioning test. Standard treatment systems are totally absent. Doctors are left with no option except to adopt alternate remedial methods to save lives uncertain of the outcome. There is no provision of digital system of X-Ray machine. Adequate number of radiology doctors and technicians to handle sophisticated ultrasound, CT scan facility are not available. Platelets, immunoglobulin, albumin or Anti-biotic are never made available. Drugs testing or drugs trials where there is no evidence whether these vaccines are doing harm or benefit has been going on without proper monitoring. In addition to these problems, issues like mal nutrition, illiteracy, absence of ante-natal checkups, and absence of marital counseling add to the number of deaths of infants and children of all age groups. This is the state of Niloufer Hospital every day.
The philanthropy and empathy for the poor and the sick, of Princess Niloufer, took the form of the prestigious Niloufer Hospital that had served, cared and nurtured many a sick, sane and critical cases for nearly six decades. Princess Niloufer Khanum Sultana was one of the last princesses of the Ottoman Empire (or the Turkish Empire). She was the second daughter in law of the erstwhile King of Hyderabad state, Nawab Mir Osman Ali Khan. It is said that, even after several years of married life when Niloufer had not conceived, she consulted various doctors in Europe and was planning to go to America for a medical visit. During this time, one of her maids died during childbirth. At that time, there was no specialized hospital for children and mothers. Niloufer’s resolve to build such a hospital materialized in the form of the current Niloufer Hospital in Red Hills.
Established in 1953 as a 100 bedded hospital to meet the health needs of mother and child, Niloufer Hospital has always been with almost 200 percent occupancy. Students of Niloufer Hospital, a premier pediatric institution in South India, proved their mettle at National and International levels. The hospital had the honor of managing significant number of critical cases, performing rare surgeries. Today Niloufer Hospital is a quaternary care hospital for Obstetric, Pediatrics, Neonatology and Maternal Fetal Medicine. It is one of the largest hospitals of its kind in Asia with advanced training in the faculties. Department of Pediatrics at Niloufer Hospital is the oldest upgraded department in the country, providing round the clock emergency services, every day immunization services, child nutrition services, school health services with dental, ophthalmic and E.N.T. In spite of all this the hospital to its discredit registers on an average 10-15 deaths of newborns and infants. Who is to be blamed for this?
According to Principal Secretary of Health Department Dr. PV Ramesh, the Infant Mortality Rate (IMR) in Andhra Pradesh is quite high. He put the (registered) figure as high as 74, 000 per year in the state. Delivering the keynote address at a State-level orientation workshop jointly organized by UNICEF, WHO and Medical Council of India in Vijayawada recently, he said that the IMR is very high among tribals (102%) and Scheduled Castes (73%) in the state. Dr Ramesh suggested that, medical colleges should play a key role in bringing down the IMR. He advised the doctors there to work in coordination with community health centers and primary health centers to promote institutional deliveries. The issuing of ‘Mother and Child Health Cards' and registering all pregnancies has been made mandatory for all hospitals, be it in the government or private sector. Dr. Ramesh also called for collective effort and commitment of doctors to reduce the number of deaths. While this is the case state wide, with reference to Niloufer Hospital he revealed while speaking to media after the recent junior doctors' strike was called off, that, every day on an average 10 to 15 children die in Niloufer Hospital.
Infants in general and with high risk infants in particular of less than thirty days old, from all the Telangana Districts, parts of Vishakhapatnam and Guntur districts, neighboring districts of Karnataka and Maharashtra are brought to the Niloufer Hospital in Hyderabad for medical and surgical treatment. In addition children of different age groups suffering from various health problems and pregnant women also go there for medical aid. Among the 500 and odd deliveries that take place in the hospital every month, when compared to normal deliveries, the high risk deliveries are more on an average. At least one third of these deliveries are through cesarean surgical operation. The general ward, the neo-natal ward, pregnant women ward, wards for other age group children are always fully occupied and the occupancy is double the bed strength. Daily admissions on an average would be around 200-250 and at any given point of time 1000 beds are occupied.
In the neo-natal ward, where the infants below 30 days are kept, on an average, at-least 200 beds are occupied always. There are separate blocks for the children born in the hospital and for those born outside but brought to hospital for treatment. This is done to avoid spreading of infections from outside. The hospital deliveries ensure sterile process and the infants are free from infection. Under weight infants (less than 2.5 KGs and sometimes even less than a 1KG), infants suffering from convulsions, from breathlessness, from jaundice and unable to suck milk born in the hospital are retained in the premature and inborn unit of neo-natal ward. Among these infants, every one suffering from serious illness is shifted to level-3 care (NICU) known as Neo-natal Intensive Care Unit for special attention. The seriousness is normally caused due to acute disorders like Jaundice, Convulsions, Respiratory infection, Congenital Heart problems and Congenital Mal-Formation of all organs as well as Intestinal Obstruction. Infants categorized under Surgical Mal-Formation are referred to pediatric surgery where medical treatment does not help. Out of these 200 infants undergoing treatment daily who include those born in the hospital and those born outside but admitted in the hospital, on average, about 10 die every day due to some problem or other. This matches more or less the infant mortality rate in India which stands at 48 per 1000 live births.
Niloufer Hospital has bed strength of 12 in the Pediatric Intensive Care Unit and 6 beds in the Neo Intensive Care Unit allocated for neonatal and pediatric critical care. There are Labor Rooms, Operation Theaters and Wards. Ideally speaking it requires at-least one nurse in each shift for every two patients in the Pediatric Intensive Care Unit. In addition six more nurses are required for contingency duty. This works out to 6 nurses in each shift, 18 put together in all the shifts and over all 24 including the contingency arrangement. Unfortunately at present the total strength available for this Unit is just 6-six! In the emergency ward, that is the Neo-natal Intensive Care Unit, for every infant one nurse is a must. In every shift the minimum requirement is 6-8 nurses for the 10 beds that are generally occupied. This works out to 25-30 for all the three shifts put together. As against this the availability as on today is just 3-three!
`When an infant patient is admitted either in the Pediatric Intensive Care Unit or in the Neonatal Intensive Care Unit, the Doctor attending on them should be free from the thought that how many among them could be saved. Instead, the Doctor should be in a position to determine that he or she should save each and every patient. This is the ethics that they learnt while they were undergoing medicine education and every Doctor feels comfortable only when they are able to adhere to those ethics. They feel that they have a responsibility to save every infants life. In the Medical Colleges they take oath accordingly. Unfortunately the physical and other connected working conditions and conditions of work currently prevalent in the Niloufer Hospital do not provide that opportunity. They are left with no option except to think that “let me save as many as possible only”. According to Hippocratic Oath (The Hippocratic Oath is an oath historically taken by doctors swearing to practice medicine ethically. It is widely believed to have been written by Hippocrates, often regarded as the father of western medicine) and resuscitation basic principles every doctor should leave no stone unturned to save the life of every patient. Unless he puts in life saving measures for at least 20 minutes it is impossible to save the life. After 20 minutes of resuscitation life may be possible, but it will be a vegetative life. However, the doctors currently working in the Niloufer Hospital are probably caught with the dilemma whether to prefer attending on 50:50 chances infants or 90:10 chances infants! The reason being, in the given circumstances, it is better to put more efforts on those patients where the chances of survival are more.
Out of 16 Ventilators to mechanically move breathable air into and out of the lungs and to provide the mechanism of breathing for a patient who is physically unable to breathe, or breathing insufficiently, those were provided to the hospital, only 4 are in usable state. As per prescribed standards accepted universally for a General Hospitals, for every 100 beds in any hospital, a minimum of 5 ventilators in full working condition are required to take care of emergencies on any given day. Niloufer Hospital, a referral neonatal and pediatric hospital with a sanctioned capacity of 500 beds, always overflows and at any given point 1000 beds are occupied with patients. This means the number of Ventilators required including the reserves should be about 50-55 minimum. In fact Niloufer Hospital being a referral hospital, the requirement is more than this. There is either absolute scarcity or meager supply of “Monitors”, “Infusion Pumps”, “Emergency Drugs “and provision for “Emergency Investigations” popularly known as ABG, (Blood Gas Analysis) Electrolytes, LFT etc.
In the absence of standard systems, as and when required the Doctors are adopting alternate methods to save the lives which may or may not yield results. For instance, in case of ACIDOSIS (renal failure) the remedial method now being adopted is, administration of sodium bicarbonate, hoping that there could be at least half correction. This might lead to over correction or under correction and the evidence of improvement to the patient is by clinical assessment.
Basic minimum X-RAY facility is available round the clock. Improvised facility of advanced form of X-Ray is not available in the hospital. While the whole world has introduced the Digital system of X-Ray machine, here in Niloufer Hospital, it is missing. The Ultrasound, CT scan facility-though highly sophisticated, is put to use only between 9 AM to 4 PM, on the plea that adequate Radiology Doctors and technicians are not available.
One can understand the functioning of the whole system through an interesting case of a just born infant-an abandoned child-suffering from “Septicemia” infection. According to the Doctor attending on the infant, the infant’s blood is full of Bacteria. The child is born pre-mature and underweight. Platelets in the body have fallen drastically. There was heavy internal bleeding. Even externally also the infant was bleeding. The Doctor is confident that, the survival depends on giving adequate platelets to maintain Coagulability (consistency) of blood in circulation. Niloufer Hospital is not in a position to make them available and the infant being abandoned the Doctor cannot afford to buy them from outside. Even if it was not an abandoned child, for the parents it is a costly affair to buy. Doctor with tears in her eyes confess that though the infant is about to die and though there is a possibility to save, she is helpless! Similar problem is with many more patients. There may not be availability of immunoglobulin, albumin or Anti-biotic. If only these are made available in adequate quantities, the number of deaths could be reduced to at least half of what is taking place today.
A Neo-Natal death is an avoidable common future. Though neonatal deaths are not totally preventable, necessary steps if initiated from the basic level, some of them could be averted. Many deaths occur due to lack of basic care and non availability of trained medical persons and facilities. Infants are brought to Niloufer Hospital from faraway places, travelling five to six hours to reach there with no medical support and unprotected from weather, temperature heat and cold (draught). Both mother and child are exposed to infection during travel. Some of the deaths occur in Niloufer Hospital are due to this. Number of such cases coming to Niloufer Hospital may be reduced, if adequate medical facilities are provided in rural areas. FDHS (Fixed Date Health Services) scheme probably is one of them. FDHS which was providing monthly routine checkups in Public Private Partnership to pregnant women should have been strengthened. Instead the Government took over them and handed over to Collectors. Risk to the pregnant women commences from 7th month of pregnancy and the delivery may happen any time after that. When it is diagnosed that the pregnant woman requires neo-natal care, it is better to transfer her to Hospital, which is known as “Transfer in Utero” (Mother and Child together). This may also reduce infant deaths.
Due to HMRI (Health Management and Research Institute) initiated and implemented FDHS program in rural areas for over two years, more than 13 Lakh women had the advantage of periodical antenatal and postnatal checkups. 27 Lakh Hemoglobin tests were performed to monitor the anemia levels of pregnant women. Iron and folic acid tablets were provided wherever required resulting in improvement of Hemoglobin levels in 75% of cases. More than 2.5 lakhs high risk cases (nearly 20%) were indentified and monitored regularly or referred to the Primary Health Centers and other higher institutions whenever they required. These high risk cases are the major contributors for the maternal and neonatal mortality. Because of early identification, risk mitigation and management by HMRI, the FDHS program yielded excellent results in reducing the maternal mortality and neonatal mortality. The program now stands crippled.
In Niloufer Hospital an activity known as “Drugs Testing” or “Drugs Trials” with Government permission has been going on for some time. Santa Bio-Technology, Bharat Bio-Technology and GSK Technology among others conduct these trials. They use Niloufer Hospital patients as the platform to test the functioning and effectiveness of the vaccines produced by them. These are supplied to the patients free of cost and on their option. Poor patients prefer them to avoid expenditure for buying them. There is no evidence whether these vaccines are doing harm or benefit. There is certain amount of risk factor involved in this and to what extent it contributes to the deaths is hypothetical. There is no fool proof monitoring mechanism to ascertain that these vaccines do not cause drug effects.
Another desirable development in Niloufer Hospital is the so called “Clinical Trials”, though they “are not” strictly speaking. It is observed by Doctors that, several infant and child deaths have been occurring due to malaria in Tribal Areas. It is also found that one of the reasons for malaria infection is “Vertical Transmission” of the disease from mother to child during pregnancy. It is more or less an established fact. Director of Medical Education permitted a voluntary organization to conduct a study on this. Preliminary studies confirmed that incidence of malaria in children in such cases is there. Based on malaria tests to pregnant woman and later to the new born child if it is found that both are positive, there is a need for further probe. To reduce neo-natal deaths a policy decision in this direction may also help to some extent.
Mal Nutrition, illiteracy, absence of ante-natal checkups, absence of marital counseling may also be some of the causes for infant and child mortality.
Who is to be blamed for the state of affairs? Is it an individual or a group of individuals or the system of governance? Reforms in Health Sector may provide an answer to this.