Callous in the ER

Seventy-year-old Ram Gopal Ojha was travelling with his family to the Vaishno Devi Mandir in Faridabad for his nephew’s wedding when their car collided with an over-speeding truck. Ojha was critically injured and bleeding profusely. His family rushed him to the nearby BK Government Hospital. “We were made to wait for two hours,” says his nephew, Naveen Ojha. “Finally, they said they didn’t have the infrastructure to treat my uncle and sent us to Fortis, Faridabad, where we were asked to pay ₹2 lakh upfront. We didn’t have the money, so we took him to AIIMS, by which time he had died.”

In July, eight-year-old Surya (name changed on request) fell from the fourth floor of a housing complex in Bhiwadi, Rajasthan. The nearest private hospital demanded payment upfront to start the treatment. Unable to pay, the family took the child to AIIMS in Delhi, but he was declared brought dead.

At 9.30pm on September 23, Fakhruddin, a sari salesman in Bhajanpuri, east Delhi, was rushing his son Rehaan to the nearest hospital. Rehaan had slipped down the stairs and fractured his hand. According to Fakhruddin, the private hospital, Shanti Mukund, told him that “the outpatient department was free only till 9pm and he would have to return the next morning if he wanted free service”. A man of modest means, he decided to take his son to the government hospital in Karkardooma, which treated the child after a three-hour wait. Complaining that the doctors had done a poor job, Fakhruddin says, “There were only junior doctors available and my son’s hand has still not healed properly.”

Money or nothing

Of the 4,667 patients who arrived at the AIIMS Trauma Care Centre in south Delhi’s Safdarjung area till August this year, nearly 30 per cent were redirected from private as well as government hospitals elsewhere.

Until August, 20 people were brought dead — an average of 2.5 dead-on-arrival patients per month. Doctors at AIIMS say that, more often than not, private hospitals redirect the patients when they cannot profit from treating them. “We have seen patients who were sent in the most pathetic conditions, without any medical staff to care for them,” says Dr Amit Gupta, a duty doctor at the AIIMS Trauma Care Centre. “Most private hospitals are really well-equipped. But when they realise that the patients cannot pay anymore, they start telling the carers to take them to a government hospital. As AIIMS is the apex centre, most of the people end up here.”

The 200-bed centre receives nearly 400 patients every month; the additional 200-odd patients redirected to it from other hospitals burdens it further. “If each private hospital in the NCR allocates 20 free beds, that will be a combined corpus of around 670 beds. This is something they are already obligated to do under the 10 per cent rule,” says Dr Gupta. In September 2011, the Supreme Court had directed all hospitals that had received government land at a concessional rate to reserve 10 per cent of their bed strength and 25 per cent of the outpatient load for patients from economically weaker sections.

Gagan D Bharti of charitybeds.com finds the situation way better than it was some years ago, but still sees a long road ahead. Charitybeds helps arrange healthcare for those who cannot afford it by liaising with both government and private hospitals. “I think the problem is on both sides. Many people are not aware of what they are entitled to and, at the same time, some private hospitals capitalise on people’s ignorance. The only meaningful way forward is through stricter rules imposed top-down by the directorate general of Health Services and other monitoring committees.”

Legally speaking

“The biggest problem is that public healthcare is an afterthought in India,” says advocate Ashok Agarwal, founder-member of the NGO Social Jurist, who has worked on medico-legal cases for the last two decades. “Three fundamental changes are required in the law, and healthcare legislations should be put on the concurrent list. In fact, public health should be a fundamental right and there should be a national law.”

As hospitals are a state subject, the onus is on individual states to mandate good practices at healthcare centres under their jurisdiction. Currently, only Assam has a law mandating free emergency services at all hospitals, private or government.

In other countries like the US, laws such as the Emergency Medical Treatment and Labor Act (EMTALA) require hospitals to accept Medicare (national social insurance) to provide emergency healthcare to anyone needing it, regardless of citizenship, legal status or the ability to pay. The situation in India is a far cry from that.

“People need to make it a parliamentary and public issue. Get the government interested in legislative changes,” says Agarwal. “The current situation is so grave that in many of the cases I deal with, I just come to an agreement with the hospitals concerned, and work on a case-by-case basis. Patients, too, have no choice but to deal with the private sector because most government setups are in an appalling state.”

Incidentally, several Supreme Court cases did set clear precedents for the enforcement of laws such as EMTALA in India, but so far they remain only on paper in the absence of concrete legislation. When a scooterist succumbed to his injuries before the nearest hospital dealing with medico-legal cases could be found for him, in 1989, the apex court had ruled in the Paramanand Katara vs. Union of India case that the obligation of medical professionals to provide treatment during an emergency overrode the professional freedom to refuse patients.

The value of such a golden rule in the precious golden hour is now felt all too keenly by Naveen Ojha. “I wish at least one of the hospitals had treated my uncle earlier… he would have surely been alive today.”