SRINAGAR, INDIAN-ADMINISTERED KASHMIR – Months after Kashmir’s Govind Ballabh Pant Hospital hogged headlines after more than 500 babies died within the first half of 2012, Dilshada Jan’s firstborn daughter was added to its death toll.
Jan, 30, says she was jubilant as her delivery date approached during October 2012. She wanted to give birth to her first baby in a government-run hospital in her hometown, Pattan, 15 miles west of Srinagar, Jammu and Kashmir state’s summer capital.
She says she did not want to go to Srinagar’s Govind Ballabh Pant Hospital, a government-run pediatric hospital, because she had read news articles and heard her community talk about the hospital’s high infant mortality rate. A government report on the deaths cited medical negligence, infrastructural inadequacies and asphyxiation.
“All of my relatives and in-laws asked me that we should shift to Srinagar for delivery, as all facilities are available there,” Jan says. “But I was adamant and didn’t listen to them.”
Jan gave birth to a girl in Pattan, but the newborn suffered asphyxia during birth and within hours developed cardiac complications and a severe blood infection, Jan’s family says. The doctors said the baby needed more blood and referred Jan to Govind Ballabh Pant Hospital.
Govind Ballabh Pant Hospital is the only pediatric referral hospital in the state, so there was no other option than to take her baby there.
“When we admitted our newly born baby in the hospital, we were surprised to see that our neonate had to share the same ventilator, which was already held by critical neonate with a problem in head enlarging,” says Jan’s father, Ghulam Rasool Khan.
Before long, Jan’s fear came true.
“Our infant was in immediate need of fresh blood,” Khan says. “But the hospital couldn’t provide that, due to which our child died.”
Khan says Govind Ballabh Pant Hospital doctors and paramedics told them the infant had died because she had already been in critical condition upon admission.
“When we hand over our children to doctors, we repose a trust on them,” Khan says. “The officials at the hospital should realize that people pin their hopes on them. So the staff members present in the hospital need to be polite rather than being ignorant and uncooperative.”
After the baby’s death, doctors quickly took away her hospital file, Khan says.
“It was so strange to see that soon after our baby died, the hospital authorities immediately took our record file,” Khan says, amid sobs. “We were not even allowed to mourn the death [of] our baby.”
The staff shepherded the family out a side exit, insisting that the main entrance was closed, Khan continues.
“We were not allowed to assemble around the wards, and our route of discharging was also different,” he says. “We failed to understand that – why they didn’t allow us to leave the hospital through the main entry gate.”
The state government and Govind Ballabh Pant Hospital authorities say the infant mortality rate at the hospital has declined thanks to action following public uproar about more than 800 infant deaths there annually. The hospital superintendent cites new codes, policies, equipment, trainings and construction in response to government investigations and recommendations. Parents and former and current employees acknowledge some improvement but scoff that most changes are cosmetic and the infant death rate remains high.
More than 3,800 infants died in Govind Ballabh Pant Hospital from 2008 to August 2012, Ravinder Singh Chib informed the Jammu and Kashmir Legislative Assembly, the lower house of the state legislature, during October 2012, when he served as medical education minister. During the first eight months of 2012, infant deaths reached 636, which is on par with figures he presented from the previous years.
But a report by Dr. Showkat Ali Zargar, director of Sher-i-Kashmir Institute of Medical Sciences, found that infant deaths in the hospital increased 35 percent during the first 4.5 months of 2012. After the public uproar about the hospital’s infant mortality rate, the government sent Zargar to investigate Govind Ballabh Pant Hospital in August.
Zargar submitted his report in October to a seven-person Estimates Committee of the Legislative Assembly. Mohammad Akbar Lone, the assembly speaker at the time, said the deaths in the hospital were not only unfortunate but also the “murder of gen-next.”
Chib said during a December telephone interview while still the medical education minister that the government offered many recommendations to overhaul the Govind Ballabh Pant Hospital system.
“The government took several measures to prevent recurrence of the infant deaths and streamline the overall hospital for the relief of the patients,” Chib says. “After the deaths were reported, the hospital system was overhauled, and things from administrative changes to implementation of various schemes and other infection-control measures were kick-started in the hospital.”
The state government removed the superintendent, Dr. Javed Choudhary, for his role in the hospital crisis, according to a source in the Department of Health and Family Welfare, who requested anonymity because they were not authorized to speak with the press.
The state is likely to start an inquiry against Choudhary, the department employee says. He has responded to a chargesheet filed against him by the General Administration Department. But the department has given special instructions not to reveal details until the Estimates Committee formally submits its report to the state government.
The newly appointed medical superintendent, Dr. Muneer Masoodi, a retired doctor, took charge of the hospital during May 2012 to revamp the system and implement new hospital procedures. He says that the overall mortality rate has decreased 35 percent to 40 percent since then, but he declined to comment on the current infant mortality rate.
Masoodi says the major problem before he took over was that the hospital operated according to codes from the 1960s.
“But I personally made all efforts to streamline the things by looking after all those gray areas to assure all implementations,” he says, “whether that is upgradation of infrastructure, purchasing of essentials or anything and release of salary on time.”
The government-commissioned report states that doctor negligence, a lack of specialists and deficiencies in their training contributed to the infant deaths. Junior doctors treated infants in critical condition without consulting their senior doctors. Employees also admitted more than one patient to a bed, increasing chances of cross infection.
Doctors often prioritized their private practices over their hospital duties, habitually coming to work late, according to the report. A doctor was on call only during “emergency duty.”
The Estimates Committee recommended a blanket ban on hospital doctors working at private practices or leaving the hospital before 4 p.m.
Masoodi says nobody in Govind Ballabh Pant Hospital now works in a private practice, even after 4 p.m.
But doctors and hospital employees say that doctors still secretly remain in private practice.
Dr. Nissar-ul-Hassan, president of Doctors Association Kashmir, an umbrella organization of more than 1,700 doctors, says private practices still hinder the hospital’s effectiveness. Instead of training medical students, senior doctors leave the hospital for their more lucrative private practices.
“The senior faculty members of the hospital should treat the patients, train the students and do their researches,” Hassan says. “The doctors leave it all up to the students and leave the hospital.”
He says there is a lack of doctor accountability.
“There is a lack of supervision by the specialized and experienced doctors,” Hassan says. “There is no monitoring and accountability in the hospital.”
The report found that a group of doctors and staff at the hospital was also part of a “drug mafia” flooding the hospital with adulterated and substandard medicine. The report alleges that Choudhary directed hospital employees to use medicine from unknown companies.
Masoodi says he removed an illegal medicine shop from the hospital that used to provide substandard medicine.
“There was [a] drug mafia,” Masoodi says. “I broke the nexus of getting substandard medicines and bought quality medicines and other necessary items from market without involving any third person.”
Masoodi says the hospital is also now training paramedical staff, nurses and sanitation staff about cross infections, bio-medical waste management and safe injection procedures under the National Rural Health Mission, created under India’s Ministry of Health and Family Welfare to improve the health care delivery system.
Many hospital employees say they were not trained earlier in hygiene, safe injection practices, or the operation of ventilators and oxygen cylinders. But new training is improving their knowledge.
“We tried our best to bring the crisis before public last year, and that didn’t only help people to know about the various problems of the hospital but upgrade our expertise as well,” says Zamrooda Ji, a senior nurse who has worked at the hospital for 25 years. “At present, we can’t say everything is good, but there have been many positive changes. From last few months, we have also learned and are still learning through trainings to deal the babies with utmost care and cleanliness.”
The government report found that the hospital staff used ventilator pipes repeatedly, developing dust and harmful bacteria.
Masoodi says that since May 2012, the hospital bought hospital equipment for infant care, including around 20 baby warmers. He says the hospital increased the number of ventilators from three to 14.
But Global Press Institute witnessed babies still sharing beds and ventilators in the hospital.
Yasmeen Reyaz, a mother who brought her baby to the hospital because of respiratory problems, says care hasn’t improved.
“There is still [a] lack of ventilators, and the officials are befooling [the] government,” she says.
Masoodi says the hospital introduced new procedures to stop spreading infections.
“We had poor sanitation and hygiene, which was the main reason of spreading infections,” Masoodi says. “So to avoid that, we have introduced dress code, infection-minimizing gowns, masks and caps. And our staff is trying their level best to ensure utmost hygiene in the hospital now.”
Checks ensure that staff wear proper uniforms and protective gear before entering the hospital, intensive care unit and other critical wards to avoid cross infection, he says.
Many parents also complained that the hospital swapped babies, Masoodi says. Now, the hospital is the first in the Kashmir Valley to use a waterproof, color-coded tagging system for newborn babies.
The Estimates Committee recommended creating Sick Newborn Care Units, a neonatal unit near the hospital’s labor room that provides care for sick newborns.
Govind Ballabh Pant Hospital has not yet established Sick Newborn Care Units, says an administration employee who requested anonymity for fear of being fired. The staff hired for the units currently work general duty.
“Around 10 staff nurses for every district hospital had been appointed, out of which six are exclusively meant for SNCUs,” the administration employee says.
The employee says this is part of a larger issue. The Department of Health and Family Welfare in Jammu and Kashmir has established Sick Newborn Care Units so far in only three of the state’s 10 district hospitals.
“The already-approved funds under the NRHM scheme for other districts are not being utilized,” the administrative employee says. “Lack of space at the hospitals for setting up such units is one of the major problems, and many rooms are being occupied by paramedics, pharmacists, nurses who do not use them.”
They use them for personal reasons, not to care for patients, the employee says.
Masoodi says the hospital will soon create these units and train doctors and nurses to man them. A new pediatric intensive care unit is also under construction. The hospital already created new wards to accommodate the high number of patients, including a pediatrics ward, a lactating mothers ward and an isolation ward.
Previous hospital authorities did not use funds available under Janani-Shishu Suraksha Karyakram, a countrywide program in which the Indian government covers the cost of medicine and medical tests for neonates, Masoodi says. Hospital authorities didn’t use this fund because the former medical superintendent delegated the money to never-implemented hospital plans.
The Estimates Committee recommended that hospital officials disband the purchasing committee that monitored hospital purchases, including medicine, furniture and beds. It advised the hospital to create a new procurement division based off the hospitals in Tamil Nadu, a southern Indian state that has one of the best health care systems in the country according to health officials.
A recently retired administration employee, who requested anonymity for fear of reprisal, says the purchasing committee still exists.
But Masoodi denies this. He says he now oversees all hospital purchases. The formerly unused funds now alleviate patients’ costs.
“I will not say funds were embezzled, but they were not utilized,” Masoodi says. “At present, Janani-Shishu Suraksha Karyakram scheme is being fully implemented now.”
He says the hospital spent 5.3 million Indian rupees (about $98,000) between June 1 and Nov. 31 on treating newborns with zero out-of-pocket expenses for their families. The hospital also provides free lunch and dinner to patients and one family member.
“Under the scheme, we provide patients and one attendant free food,” Masoodi says. “And newborn babies are given free treatment up to the first 30 days post-birth.”
A Canadian couple also donated 2,000 Canadian dollars ($1,950) to Govind Ballabh Pant Hospital during January 2013 to improve the hospital’s neonatal care after they read online news reports of the infant deaths, Masoodi says. He plans to use the funds once the check clears, which takes up to one month for foreign checks.
When asked whether the hospital had received other donations, Masoodi responded that the hospital is relying on its own funds.
Masoodi says that Govind Ballabh Pant Hospital is the first hospital in India to provide free surfactant treatment for premature babies with respiratory distress syndrome.
But patients’ families deny that most facilities are free.
Ghulam Rasool, a father who brought his baby to the hospital because he was continually vomiting, says that some hospital management changed, but it hasn’t necessarily improved care. He also cited new fees.
“The authorities have devised [a] new trend of adding to our miseries by charging money through different tests earlier, which was not there in the hospital,” Rasool says. “One has to get these tests done many times during the day.”
Each test now costs at least 10 Indian rupees (18 cents).
Masoodi explains the hospital testing costs.
“For laboratory testing purposes, we have free testing for 0- to 1-month neonates and all pregnant women, delivered mothers,” he says, “and [the] rest is being charged according to government rates.”
Present and past hospital employees, most asking for anonymity because they fear reprisal, say they have not witnessed any major improvement in the hospital's infant death rate. They accuse the hospital of changing tactics so that the deaths go unnoticed.
One hospital employee who works in the administrative department, who requested anonymity for job security reasons, says hospital workers are told to admit fewer patients.
“We have been given special instructions not to take many admissions,” the source says. “So it is quite obvious the death rate will be low as compared to last year and earlier situations when there used to be more admissions and more deaths.”
Sources say that many hospital employees hide the number of deaths by removing the patients’ records soon after death and by forcing grieving families to leave by less-public exits.
“The route to discharge the patients has been changed so that the other patients in the hospital don’t come to know about deaths as such,” says another former employee in the administrative department who requested anonymity for fear of reprisal.
Hassan says that authorities’ claims of improvement are just cosmetic treatments to give the illusion that everything is better.
“It is quite surprising to see when the officials from the pediatric hospital try to project that everything is going smoothly, as the only difference is that when the hospital was in limelight, the authorities failed to hide things,” he says. “But at present, the hospital is dying a silent death.”
Masoodi says that all the above allegations are baseless and denied to elaborate further.
“We need to have a vibrant atmosphere,” he says, “where instead of blame game, we should try to work with dedication to make the functioning of health issues hassle-free.”
Hassan says that the Govind Ballabh Pant Hospital officials’ statements are deliberately covering up the hospital’s negligence and inadequacies.
“The officials who deal with the hospital have not learned any lesson from the past happenings,” Hassan says. “There is still mismanagement and burning crisis of private practice in the hospital. Thus, all these loopholes affect the overall quality of the health care service and lead to further deterioration in the health of a patient.”
