In anger and anguish

( Old post from Archives,dated  Dec 11,2011 from Viewpoints;  http://chronicler-abhi.blogspot.in/2011_12_01_archive.html )

The recent fire episode at AMRI (Advanced Medicare Research Institute), Kolkata, has sent the nation, immune though it may be to regular assaults on its sense and sensibility, into a sense of shock. Picture the following:

- A patient in the ICU ( Intensive Care Unit), unconscious and on life-saving equipment which restricts movement, meets his death in an overheated gas-filled chamber where he had come, paying a lot of money, for good treatment

- A staff nurse , who has come all the way from Kerala to earn her living, perishes in the blaze

- Patient relatives stand outside the blazing building, which has closed its doors on them, helplessly watching their relatives die behind glass walls

To die prematurely is bad enough; to die this horribly is atrocious. I feel shocked, and ashamed as a medical and healthcare professional that precious lives have been lost due to sheer callousness.

People would have gone through the minutae of the incident by now, but to recapitulate the enormous lapses leading to the loss of human lives:

- The hospital had been warned by the Fire Department about the illegal storage of materials in the basement, which it callously chose not to adhere to. It carried out illegal constructions and storage of materials in the basement, flouting all rules and regulations

- There had been earlier incidents of fire in this very hospital, so what was done to strengthen the systems of fire-fighting?

- For heaven’s sake, this was a NABH-accredited hospital (supposedly a stringent system of certification) which was supposed to carry out fire mock drills and have its firefighting systems in place! What was the NABH (National Accreditation Board for Hospitals and Healthcare Providers) doing when it awarded the certification to the hospital?

- During an earlier incident of fire in the same hospital this year, a security guard was reprimanded for informing the Fire Brigade (cover-up attempt to hide lapses?)

- Fire alarms and fire sprinklers were not working/ switched off ( in a luxurious, well-furnished superspeciality hospital!)

- This is criminal- People who came to help, including patients’ relatives, were pushed away from the building by security guards, saying that they would control the fire themselves and there was no reason to panic. Media reports say that people who wanted to shift patients immediately were told that they would have to pay the outstanding bills first!

- Staff response was inadequate in fighting the fire. Whatever happened to those fire-fighting protocols which are a mantra of any hospital accreditation system?

- There was precious time lost in unsuccessful attempts in fighting the fire. The fire brigade was informed after 1.5 hrs, when the fire was already out of control. Which emergency management team worth its name does not know when to call for help?

- This is shocking- initial announcement of Rs. 3 lakhs compensation for the dead, and then increasing it to Rs. 5 lakhs on being pressurised. This sabji- market style of dealing is typical of unscrupulous businessmen, but in a healthcare facility? Atrocious.

- Not a word of condolence on the hospital website for the better part of a week after the accident. Survivors’ and dead patients’ list put up on the website after a gap of more than 16 hours!

- A hospital functionary initially dismissed the fire as a “minor” incident !

- There was no senior hospital functionary present on the spot even when the fire went out of control, leaving the control to a relatively less-empowered night administrator , Whatever happened to the “chain of command” that is supposed to operate in these situations?

At the same time, one must acknowledge the efforts made by some of the staff to fight the blaze and help the patients. Two nurses perished, sacrificing their lives selflessly to save the patients’ lives. One salutes these brave souls who acted true to their profession. Twenty of the staff were wounded, and were admitted to hospitals after the incident.

A lot of voices are being raised against private healthcare institutions, in Kolkata. I believe these are knee-jerk reactions. Not all private hospitals are this atrocious. There are many good private medical institutions in this country. Having worked with a leading national chain of hospitals, in Delhi, I can confirm that this was never this bad with us. We had regular fire drills, the fire protocol RACE (Rescue- Alarm- Confine- Extinguish) was firmly etched into our psyche, and though the system was not perfect, just like any system never is, we were always confident of handling any exigencies. There had been incidents of fire, even in the hospital basement, but these were swiftly dealt with. And I am sure no one would have asked fleeing patients to settle their bills first. That was not our way of operating.

I also believe that the malaise does not extend to private hospitals alone- the government-run SSKM hospital has just been found to store piles and piles of paper in its basement. I heard a doctor from the state-run Calcutta Medical College and Hospital (CMCH) confess on television that the hospital had been pulled up by an audit committee for “wasting” money on fire extinguishers which were rarely used. If Mamata Banerjee uses this incident to vent her ire against private hospitals without cleaning her own stables, she is making the biggest mistake of her life. If SSKM or CMCH burn, whom will she haul up? She would have no Todis or Goenkas to blame. To quote, “Physician, heal thyself.”

So what was it that set AMRI apart? I believe it was the greed for making money at all costs- cutting all corners and throwing all rules to the wind. And also a criminal disdain towards humanitarianism. Negligence is a part of the Indian psyche, but what happened at AMRI was criminal. Stoking fire risks consciously is criminal. Not allowing people to be rescued while being totally aware of your deficiencies is criminal. Haggling sabji- market style over compensation amounts is criminal. It all depends on the psyche of the management, and the attitude of the government - allowing business houses with little or no competence in running healthcare institutions , to run super-speciality hospitals with reckless apathy for regulations and human lives is criminal. Running a hospital is not a matter of joke.

It does not extend to fire safety alone. AMRI has been recently ordered to pay a huge amount of compensation in a medical negligence case. Bad medical care is bad enough, bad and apathetic medical care in “five-star settings” is atrocious and unbearable. Patients do not come to hospitals for having a pizza or coffee- they come to have basically good, safe medical care.

The second part is the medicopolitical situation in West Bengal. The healthcare sector has long been in the doldrums in this state, and needs urgent cleaning up. Why else are patients still going to Southern states for treatment? I remember seeing as a medical student, on my way to my medical college at Mangalore, Karnataka, the trains bound for the South, packed with patients going for better medical care to Apollo Chennai, Shankar Nethralaya and CMC Vellore. How else other than a culture of mediocrity does one find that a hospital like AMRI, whose ICU was famously declared by doctors from Sir Gangaram Hospital, Delhi as an “Intensive Confused Unit”, is perceived as the second best hospital of Kolkata? The malaise extends to public healthcare institutions also, where newborns are washed with acid instead of water and die at a government hospital in the district, and paediatric deaths at hospitals keep coming back every few years like a wayward comet. Beyond pulling up government hospital directors in the glare of media, the Chief Minister, Mamata Banerjee, who is incidentally also holding the healthcare portfolio, has got a lot to do. The misrule of the Left Front is past, the time to do something is NOW!

Going into the AMRI incident, one finds that there was no culture of safety at the hospital, despite it being a posh and accredited hospital. How does one go about creating a culture of safety? It comes about by the creation of an efficient fire- fighting system that includes : a) Preventive measures (deterrants) such as good housekeeping, following of fire regulations w.r.t. structure and function ( for eg – no inflammables near electrical points, oxygen cylinders to be kept chained always, no inflammables near open flame sources, regular checking of all electrical equipment including electrical panels), regular training, regular drills and following of ALL fire department rules with regards to usage and storage ; b) Corrective measures (important in case of an actual conflagration) such as fire extinguishers, water hydrant system, sprinklers, smoke detectors, automatic fire alarms, manual fire alarms , a fire warning system ( such as Code Red ) etc. Since this isn’t essentially a technical article, I won’t get into the details, but only emphasize that the focus must always be on the CULTURE of safety, something we habitually lack in this country. True to form, the systems to effectively control fire were missing at AMRI, a place where patients came, paying premium amounts, just for better medical care. When deception of this sort occurs in a private healthcare setting, it pinches even more. Without doubt, the Todis and Goenkas have shown criminal negligence and ought to be slapped with the strictest punishment possible. The same holds true of anyone else who violates hospital safety norms.

Going forward, do we learn anything from this massive tragedy? The incidents at Stephen Court, Kumbhakonam , Uphaar Cinema are still fresh in the memory. The figure of 92 deaths is more than statistics- it is a painful reminder that 92 families have had their relatives snatched away just because of colossal criminal negligence. The West Bengal government must ensure that its now-instituted efforts to ensure fire safety do not end up meeting the fate of so many other governmental plans.

I believe the time has come for some kind of regulation of healthcare. Unscrupulous elements such as these can flourish only in an environment where human life is cheap and the healthcare sector is neglected, left only to the tender mercies of careless hospital authorites. There is enough space in this country for good private and public sector hospitals- both can co-exist. They have been doing so in the US and UK, with the only difference that they are subject to regulation. Hospitals have a higher level of responsibility than other enterprises- we are dealing with precious human lives here. The healthcare regulation bill has been lying in the parliament for years- it is time it was taken seriously. If the government sees it fit to regulate aviation, retail and insurance, surely it can do so for healthcare. Why this disdain towards this vital and important sector? Which country which claims to be civilized can boast of such dismal performance in healthcare such as we do?

The role of the administration and the government in this tragedy must also be investigated, and those guilty, if any, must be punished. The government has a stake, albeit a minor one, in AMRI, and it simply cannot wash its hands of all responsibility. Why was the government not keeping a tab on the affairs at AMRI? Why did the Fire Department wait from July till now, for action that never came about? An act of omission is an equally bad crime as an act of commission.

And then, there are good private hospitals and there are bad ones. In the heat of the moment, let us not club them together. Let us learn to sift wheat from chaff . The AMRIs of this world cannot wipe away the good work that Shankar Nethralaya, CMC Vellore or St. Stephen’s, and even some of the national chains of hospital, have done. Some of them may be expensive, but in terms of medical care and adherence to safety, they are doing a good job. Healthcare worldwide has seen a co-existence of public and private systems. Please let us not club all private hospitals as bad, and all public hospitals as good. That is dangerous and naïve.

Let us just focus on good medical care, and safety of patients. In the words of Hippocrates, the founding father of modern- day medicine, “Primum non nociere” (First, do no harm).If we remember this dictum, and adhere to it, there will be no more gory incidents such as the AMRI tragedy.