Kerala, the tiny little state at the tip of the Indian peninsula is known for high health standards, compared to other Indian states and almost comparable to developed nations, with (1) the Infant Mortality Rate of 12/1000, compared to 91 for ‘low-income countries’ generally, (2) birth rate 40% below that of the national average, and 60% below that of ‘poor countries. Kerala’s birth rate is 14/1,000 females and falling fast, compared to India’s 25 and US’ 16.(3) life expectancy of 75 years at birth, compared to 64 with the rest of India and 77 in the US. Female life expectancy in Kerala in fact exceed that of the males, as in the so-called ‘developed world’, and (4) Maternal Mortality Rate of 1.3/100 live births, the lowest in India. The reasons for Kerala’s unique trailblazing health standards are (1) political awareness of her citizens. Kerala holds the unique record of having elected a Communist government to power through the ballot, for the first time ever in the world. Progressive policies of the leftists have shown the door to policies and practices that weighed heavily against those belonging to the ‘lower casts’, with those belonging to the higher ones stopped from having a free run at the expense of the former. There was a time when women belonging to lower castes were barred from covering their breasts in public. The shadow of those of the lower castes was not supposed to fall on those belonging to the higher castes when they met or crossed each others’ paths. These atrocious practices are history now. The leftists opened the door of the state’s efficient healthcare delivery too to the underprivileged. Kerala has a pattern of voting to power leftist and rightist political alliances alternatively, thus keeping stagnation of policies, including that of health, at bay. (2) High literacy rate of Kerala’s citizenry which stands close to 100 %.(3) positive influence of social reformers like Sree Narayana Guru, Ayyankali, Kuriakose Elias Chavara, and Chattambi Chami.(4) land reforms captained by leftist governments in power which ensured availability of land to a vast section of her population which enabled them to farm by themselves and meet their nutritional requirements, adding to their health positively.(5) availability of healthcare facilities, both basic, provided by public facilities, and advanced, provided predominantly by private-owned facilities. The health indices mentioned above would not have been realized were it not for a rather active policy of primary prevention that operated through Universal Immunization Programme and quality antenatal and perinatal care which were undertaken with undiluted earnestness and dedication, and provided in all sincerity mainly by the buoyant public healthcare facilities, especially the numerous Primary Health centers that dot the state, while the private-owned healthcare facilities unfortunately fell to the lure of over-corporatization, where profit- making took precedence over dispensation of humane and ethical medical care.There are about 2,700 medical institutions run by the government, with 330 beds/100,000 population, making it the highest in the country, contributing positively to Kerala’s high standards on the health front, a phenomenon which came to be recognized by the United Nations as the ‘Kerala model of development’.
Some called Kerala ‘God’s own Country’. In the very same ‘God’s own country’, 46-year old Murugan, a migrant laborer from Nagarcoil, a city in the neighboring Tamil Nadu met with a road traffic accident at 10 pm of August 7, 2017 near Ithikkara, close to the city of Kollam on the National Highway 47 .Murugan had no family or relative with him in Kerala. He was riding a two-wheeler with his 24-year old friend, Muthu. Police took murugan and his friend to a private hospital in Kollam city, where Muthu, with minor injuries was admitted and Murugan, diagnosed with intracranial bleed was advised emergency surgery. The hospital which lacked a neurosurgeon and ventilator facility provided first aid to Murugan and referred him to another private hospital in Kollam city in an ambulance owned by a charitable trust. The private hospital to which Murugan was taken, redirected him to another private hospital within the same city, as it lacked a neurosurgeon. The third hospital too refused to treat Murugan as ‘he lacked a bystander’. He was then rushed to the state’s premier Medical College hospital in the capital city of Thiruvananthapuram, located 75 kilometers away. There, the ambulance crew was informed after three hours that there was no ventilator available for Murugan. Enquiries for availability of ventilators to treat Murugan in the capital city bearing no fruit, he was taken all the way back to a privately owned ‘medical College’ in Kollam, this after confirming availability of a ventilator which was free to treat Murugan. The medical college realizing Murugan’s lack of financial capability to pay for his treatment, and absence of a responsible bystander to take responsibility for the expenses, refused admission. The hapless ambulance crew took Murugan to the state-owned District Hospital at Kollam, where he was declared ‘brought dead’. This, after about seven crucial hours of travelling and knocking at the doors of five hospitals, both private-owned and public, in a state which boasts of being a ‘model for development’, particularly with respect to healthcare dispensation. Simply put, hospitals in ‘God’s own country’ refused to admit and do all that was needed to be done to save a financially poor migrant laborer with head injury sustained in a traffic accident in the wee hours. Kerala played an insensitive and inhuman host to Murugan, a laborer of humble means hailing from the neighboring state of Tamil Nadu. Kerala’s Chief Minister later apologized to the family of Murugan on behalf of Kerala’s citizens, which was insufficient to raise Murugan from the dead!
As usual, agencies were pressed into the time-buying exercise of ‘investigating’ the shameful chain of events that killed Murugan on the streets of the ‘model state’. The press, print and visual went on an overdrive to report the shameful incident, and to throw brickbats at ‘heath-care’ and it’s custodians, already suffering from loss of credibility and tarnished reputation, and struggling to shed their coat as money spinners and ‘wayside burglars’(as described to me years ago by an irate relative of a patient who was being treated in one of the numerous corporate ‘hospitals’ in Kerala), out to make huge profits by hook and by crook, tearing asunder the very nobility of a profession that caters to the health of citizens, making a mockery of the Hippocrates Oath taken by doctors at graduation .
What was the ideal to have been offered to a patient like Murugan brought to the doors of the Emergency Department of any hospital anywhere in the country and the world, irrespective of time?
Considerations like soliciting money in the name of ‘advance’, as is rampant in corporate private behemoths that call themselves ‘hospitals’ should not crop up at this crucial time. The patient has arrived at the hospital seeking emergency medical care and not to book a party for his daughter’s wedding! Moreover, nobody is expected to walk around with stacks of currency in his wallet to pay ‘advance’ for emergency medical treatment in case he meets with an accident.
Irrespective of the financial clout of the patient, and availability of ‘responsible bystanders’, the treating team in the Emergency Department is supposed to stabilize the patient in case of hemodynamic instability(if the blood pressure and pulse rate are precariously abnormal). The next thing to be done is to secure the airway of the patient (to ensure unhindered breathing, or remove adverse factors if any, that might interfere with respiration to cause death), especially if he/she is unconscious. This might require placement of a tube into the patient’s trachea (wind pipe), a procedure called intubation. Every hospital is supposed to do these minimum procedures, irrespective of the patient’s financial wherewithal or availability of ‘responsible bystanders’, in the interest of the patient’s life. Law demands that the hospital bear the expenses incurred up to this point. The same holds true even if the identity of the patient is unknown. Once the patient is stabilized, the hospital authorities along with the police can initiate steps to establish the identity of the patient. At no step till this stage is a hospital supposed to withhold treatment on any grounds whatsoever, including the patient’s financial capabilities or presence of a responsible bystander, or lack of both. Once the patient is stabilized, he/she must be subjected to investigations, both basic, and those to evaluate the extent of injury, and to exclude other injuries, which will include CT scans, ultrasound scans and X-rays, as indicated. If investigations reveal intracranial bleed, like murugan did, services of an in-house neurosurgeon become imperative.
Once a patient is intubated, the requirement of a ventilator takes centre stage, as a ventilated patient requires a ventilator to support respiration. It is at this stage that a ventilator becomes an important requirement. As ventilation is provided in ICUs, ICU beds too become an inevitable requirement now.
If ventilators and ICU beds are not available in the hospital, (as was the case in many hospitals at the time when Murugan was being shunted from one hospital to the other, thanks to innumerable cases of fever including H1N1, with severe respiratory infection, which had taken up numerous ventilators and ICU beds in hospitals across the state), or if a neurosurgeon is unavailable in the hospital, the hospital authorities may transfer the critically injured, but stabilized patient to another hospital only after availability of a ventilator, ICU bed and presence of a neurosurgeon are ensured by the referring hospital through a direct doctor-to-doctor communication, accompanied by valid and detailed reference notes. The patient should ideally be transferred in an ambulance with ICU facilities, accompanied by a doctor, nurses and other relevant staff, especially security staff to prevent manhandling of accompanying personnel by patient’s relatives, if any, (as has become the norm in the country due to numerous factors), in the event of an unforeseen incident like clinical deterioration or even death of the patient during transportation. This is not absolutely mandatory, nor is it mandated by law, but may be undertaken out of humane consideration for a critically injured patient with no responsible bystander to accompany him.
If a ventilator, ICU bed and a neurosurgeon are available, which was not the case with Murugan, the stabilized patient must be treated in the ICU, and must be offered all that needs to be done, including surgery even if there are no bystanders. This is undertaken solely in the interest of the patient, and stands legal validity and permission. Considerations like ‘who will pay for the patient’, and ‘how can advance be solicited, and from where’ should not crop up, and must not even be considered. The patient must be treated. That is all! If during the course of treatment, the identity of the patient is established, and if responsible bystanders arrive at the scene on being alerted, they might be requested to pay the expenses incurred thus far.
Two possibilities exist at this stage: (1) the patient’s bystanders, willing to continue treatment in the hospital will chose to do so by paying for his treatment. Or, (2) if they find the expenses unaffordable, and beyond their means, might request the patient to be shifted to another hospital of their choice, where ‘cheaper treatment’ is available. The treating doctor, after assessing the risk: benefit ratio of transporting the patient who is being treated, might concede to the bystanders’ request, or advice against their decision. If they persist with their decision to transfer the patient, the treating doctor must make arrangements to transfer the patient accompanied by responsible and trained medical personnel, preferably in an ambulance with ICU facilities. These days, such ambulances manned by trained personnel are available on rent, the services of which can be availed of. A detailed treatment report or summary must be issued by the treating doctor for reference of the doctor who will be treating the patient subsequently. The doctor must also ensure that a responsible bystander signs a mandatory form available in most hospitals when a patient is being ‘discharged at request’, wherein the possibility of death of the patient during transportation is explained to the bystanders, and their understanding and acceptance of such an eventuality is recorded.
Financially insecure Murugan with no ‘responsible bystander’ accompanying him was thus undoubtedly denied proper attention and treatment by a number of hospitals that shameful night. Due care was not exercised when he knocked at the doors of many hospitals, which laid bare the chinks in the enviable armor of the ‘Kerala model’. He was denied treatment because he had no ‘responsible bystander’ (which usually means a person who will accept responsibility to pay for his treatment), and because he looked the type ‘who might not be able to foot the bill of treatment, or pay an ‘advance’
What can be done to prevent another Murugan from succumbing to the insensitive, insensible and money-avaricious attitude of hospitals that are supposed to heal the sick, irrespective of their financial capability or any other consideration, not only in Kerala, but the entire Indian nation? (1) The inhuman and insensitive practice being followed by private ‘hospitals’ to demand ‘advance’ from patients reporting to Emergency Departments with dire emergency including road traffic accident and other acute medical conditions like stroke or heart attack, where priority must be given to treatment and nothing else, must be banned legally. Demanding ‘advance’ simply does not augur well for the nobility of the science of healing that medicine is all about. Advance is collected to cover the expenses incurred during initial stages of stabilizing and assessing the patient. The government must put in place a mechanism by which expenses incurred by hospitals equivalent to ‘advance’ sought are refunded to the hospital, preferably by the government itself. After all, don’t the taxpaying citizens deserve the government’s largesse? (2) hospitals in the public sector need to be upgraded and suitably equipped with man and machine to provide state of-the-art healthcare being provided in prohibitively expensive private corporate hospitals, such that the so-called ‘poor’ among the citizens will also gain access to quality medical care. ‘Lack of funds’, which is the usual excuse of the government called to upgrade its hospitals can easily be circumvented if a menial sum of money(like fifty rupees) is collected along with OP tickets as consultation fees. Considering the large number of patients seeking consultation as outpatients in government hospitals, a large amount of money can thus be mobilized to upgrade the hospitals. Such attempts are traditionally shouted down vehemently by the leftist outfits in the state, on the popular surmise of ‘fleecing the common man’. Things will be much easier for the common man if he decides to set aside a small fraction of the money he spends without second thoughts for his booze and smoke, to pay for consultation in the OP in a government hospital. (3) The government must place some kind of a control and lay down regulations on the money being fleeced by the over-corporatized private hospitals. Involvement of private hospitals in healthcare has stripped the latter of nobility, humanness and sensibility. This is not to forget substantial and positive contributions of private hospitals, especially those managed by the Catholic Church, and other religious bodies to spruce up healthcare dispensation in the state at affordable rates, prior to these times of corporatization and naked greed for quick and big bucks. Involvement of private players in medical education in the garb of ‘self-financing colleges’ that has resulted in making a mess out of medical education is only an extension of the greed for money among private players, and the geese that lay golden eggs that they have smelt in the noble profession that medicine was, once upon a time. A cursory glance at the bills being churned out of private hospitals under silly and preposterous subheadings are often unreasonably inflated, which vouches for the ‘wayside burglary’ being indulged in by private hospitals, as the result of which the very thought of approaching a private hospital for his health needs sends shivers down the common man’s spine! (4) A comprehensive health insurance with the participation of every citizen must be put in place, especially to cushion the financial burden in times of medical emergency and even during continuing care. (5) one of the most important factors which has doctors and other staff decide ‘not to take the risk’ when a patient like Murugan is brought to them is the fear of physical and verbal abuse of the most nasty quality, and often murderous quantity, being let loose by bystanders and ‘well-wishers’ who appear out of nowhere. Medical personnel must be provided due protection and such attacks made legally punishable, especially against physical assault let loose on them in the surmise of ‘medical accidents’.
Had doctors and other staff in the hospitals which turned away Murugan decided to treat him without ‘responsible bystanders’, and should some complication or unforeseen adverse outcome emerge from that treatment, a possibility that inherently is present during dispensation of medical care, as what is being dealt with is human body which behaves unpredictably in the event of disease and also when prescribed medical care meant to heal it is being provided by best of hands and facility, unlike the predictability of an automobile at a service station. The state of affairs that exists in the state today is for people, including those throwing stones at the hospitals which turned Murugan way, to turn around and ask ‘why did you guys decide to treat Murugan without responsible bystanders’! This must change, and change right now!