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If I was the chief secretary of Uttar Pradesh Rajiv Kumar, and if I was to hand over tomorrow to Chief Minister

my inquiry report into the

children's deaths, the challenge before me would be: despite everything the public knows and much more that it doesn't, do I really know if those kids died due to a shortage of oxygen?

I don't, because there are no bodies to examine medically. Long before one of India's biggest news stories this year escalated, hospital authorities had forced parents of dead children to go home to their rural hinterland in the dead of the night.

As we speak, those 23 children lie buried a few feet below the ground in villages scattered from eastern Uttar Pradesh to Bihar, and possibly Nepal. All are buried because, apart from Islamic tradition, even Hindu infants are not cremated. So how can we tell if their lips, fingertips and toes were blue, among other signs? How do we know if the children choked to death as oxygen ran out?

Depending on whether you like or hate

and Yogi Adityanath, you would have already reached your verdict on this heart-breaking question.

But the answer is a little more complex than the "yes" or "no" you have arrived at.

The story of the dead children of Gorakhpur is about poor governance over years, maybe decades — not just medical negligence. Just like the story of dozens of kids being sodomised and killed in Noida's Nithari was not just the story of a psychopath — but equally the story of poor governance — of a town where municipal cleaners did not clean a huge drain for ten years so the body parts could never be detected.

The Gorakhpur region is one of the filthiest areas of Uttar Pradesh. Vast parts of the city don't even have an underground sewerage system, forcing people to use septic tanks or defecate in the open. The villages face the same sanitation issues that cities do but successive governments have just not bothered to build means to keep villages clean.

Have you ever thought of a very basic question: you know where the city's waste goes, and how it's collected, but is waste collected in a village, and where does it go? Well, nowhere. A filth time bomb is ticking away in rural India because lifestyles are changing there and the same chips packets and water bottles and other urban non-biodegradable waste is choking the landscape. But governments seem to think that rural citizens in India still live the idyllic, simple lives they did decades ago.

Add to this (and this is one of my favourite cribs), rural India has virtually zero monitoring of how government funds are spent – and the same people spending (district magistrates) are the same people monitoring.

As we know very well over the five years at Gaon Connection, rural India is not the priority of mainstream media by a thousand miles. So Gorakhpur is what happens when governments don't have any way to monitor poor governance by local functionaries, and when the mainstream media rarely covers public health — except when 23 children suddenly die.

And why this fake chest-beating over last week's deaths at the BRD Hospital when nearly 2,000 children die at the same hospital every year, and about 10,000 children have died at the same hospital over the past decade?

Governments in India have largely abdicated their role in public health, taking it for granted that blood-sucking but better-run private facilities are doing the job anyway. When what remains is just not monitored, Gorakhpur happens.

When encephalitis was killing thousands for years, why weren't villages cleaned up? Why weren't citizens told in innovative ways what was causing the disease wiping out their children? When other major hospitals in UP bought liquid oxygen directly from manufacturers like INOX or Lende Gas, why was an intermediary, Pushpa Sales, given the BRD contract for years? To siphon money because these two companies are known to not give kickbacks as a strict policy? How was the hospital principal Rajiv Mishra's wife even sitting on his chair? How was the celebrated Dr Kafeel running a private service and even advertising it on the walls of the government hospital? Why were warnings of oxygen shortage ignored? Why was money not disbursed to the oxygen vendor in a crisis though the principal had adequate money in his account?

The more we scrape the dust off the story, the more rot we find.

(Lucknow-based Misra is a radio storyteller and founder of Gaon Connection)