Over 2,600 deaths in a state-run hospital since January has put a wider focus on absence of healthcare in rural India.

Gorakhpur, Uttar Pradesh, India – In the early afternoon of August 22, Pawan Tiwari and his wife Rinki sobbed inconsolably in front of the Baba Raghav Das (BRD) Medical College in the northern Indian city of Gorakhpur.

“Oh, my boy, oh, my boy,” wailed Tiwari’s wife Rinki while sitting on the floor.

Parents of other children at the hospital tried to comfort the couple sitting outside in the shade of a tree.

Doctors had informed Pawan, 35, that his six-year-old child, Naitik Tiwari, was dead. But shortly afterward, Pawan’s brother, Anjan Tiwari, emerged from the hospital to tell him that his son was still breathing and doctors were struggling to save him.

The couple rushed inside the ward. They peeked through the glass window of the paediatric intensive care unit to look at their son, their eyes swollen from crying.

As Pawan and his wife left the ward, his brother broke down. He told me that he had given them false hope; a doctor had told him that the child was unlikely to survive.

In August, the deaths of more than 60 children over five days at the hospital in northern Uttar Pradesh (UP) state, allegedly due to oxygen failure, caused public uproar. Children have died from infections and conditions such as Japanese encephalitis. Naitik was among the 415 children who died in the month of August, according to the official data provided by the largest government hospital in the region.

Deaths of children at the BRD hospital 2014 – 1,845 2015 – 2,132 2016 – 2,729 January-October 2017 – 2,600

In the first 23 days of this month at least 354 children, including 231 newborns, have died, taking the death toll to more than 1,000 since August.

Most of the children who arrive at the hospital are malnourished newborns, Dr PK Singh, the college principal, had told Al Jazeera in August. Flooding in the region – in eastern UP and western Bihar states – has caused widespread infections, he added.

“Children are already infected; they die in the first hour of admission. The patient load is too much, nearly 4,000 patients are coming daily. We can’t refuse to admit them,” he said, adding that staff place multiple children onto a single bed. There is one doctor for every 17 patients, he said, when a normal ratio should be one for every ten.

“In our country, the neonatal mortality rate per 1,000 live births is 27 but in UP it’s 43. Most of the deaths at neonatal stage are due to breathing problems. The next big cause is infection,” said Professor KP Kushwaha, a former principal of BRD Medical College.

“By the time the infants arrive at the hospital their condition is already in critical stage. It becomes difficult to save infants at this stage,” said Kushwaha, a renowned pediatrician, adding that the institutional approach toward neonatal care must be overhauled, to include specialised care in primary and community health centres across the region.

A woman looks into the intensive care unit (ICU) at the Baba Raghav Das hospital [Cathal McNaughton/Reuters]

The deaths at BRD, the only major state-run hospital in a 200km radius has put a focus – in a country that spends only 1.2 percent of its GDP on public health – on a facility that cannot adequately care for its patients and the wider, impoverished region that desperately needs the government to provide healthcare infrastructure.

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Vandana Prasad, the national convener of People’s Health Movement – India, a network of 1,000 non-government organisations, told Al Jazeera it is a “failure of the entire system”.

“I take the point that some children come to BRD medical college in critical condition, but what has been done to address this situation? Why wasn’t health infrastructure at primary and community health centres strengthened [by the government]?” she asked.

“The BRD medical college needed improvement, as it faces shortage of doctors, beds and ventilators. Why were not these issues fixed?”

The People’s Health Movement – India said in a statement about the deaths at BRD: “The entire country has been horrified at the recent deaths…This is the net result of decades of grossly inadequate investment in the public health sector and services… This drastic situation, compounded by misgovernance, mismanagement and corruption has been a powder keg just waiting to ignite year after year, with the resultant loss of innocent lives.”

Patients face long waits

Naitik first developed a fever on August 10. He initially responded well to medicines but later complained of a stomach ache. His parents took him to private clinics in their home district of Gopalgunj, where doctors diagnosed him with typhoid fever. A week later, as his fever continued, local doctors referred him to BRD Medical College.

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Pawan, a garment factory worker in the western state of Gujarat and the main breadwinner for his family, had travelled more than 100km from his village of Khatwanian in the neighbouring state of Bihar to reach the hospital.

He hired a local taxi and left for the hospital with his son, wife and brother on the night of August 18. Naitik was admitted to hospital that night, but doctors said he should have come earlier. In medical terms, his condition was critical.

“We will do our best. Have faith in God,” the doctors had promised a distraught Pawan.

The day after I met Pawan and his wife, at 11.30 the next morning, I went to visit Naitik at bed number 15 in the paediatric ward. He wasn’t there. There was another child in his place. No one could tell me what had happened to Naitik. His parents weren’t there. Later the hospital officials confirmed the child died of encephalitis.

I went to the outpatient department where about 200 people were in the queue, waiting to see a doctor.

Among them was Ramawati, 65, who was with her 30-year-old daughter. They live two kilometres away and had already been waiting in the queue for two hours.

Seventy-year-old Dashrath Prasad had travelled 80km for a follow-up appointment. He stood in the humid, narrow hospital corridor, dabbing the sweat from his balding head with a white cotton towel draped over his right shoulder.

The clerk registering the patients sweated profusely. Every now and then, he stood up to reprimand patients who tried to cut the queue.

Dashrath, wearing a dhoti – an unstitched piece of cloth worn around the waist – and a kurta (a shirt), had come 15 days after his blood pressure shot up. But the last doctor who saw him was on leave and Dashrath was forced to register again.

Meanwhile, Dashrath has still not seen the doctor after standing in a queue for three hours.

The patients complained of long waits and indifferent staff. They lamented that one day goes by before they see a doctor; another day if diagnostic tests are required.

“I spent Rs 80 ($1.25) to reach the hospital. An entire day will take to see a doctor,” Dashrath said angrily. “Poor management by the hospital administration is killing patients.”

Overworked doctors

Doctors said they were overworked as the hospital was understaffed. Between 9am to 2pm, outpatient doctors said they see between 200 to 300 patients.

“We work under so much pressure due to the high number of patients that we are not even able to discuss about the diseases with resident doctors. This is a teaching hospital, we are also required to research on diseases but most of our time goes into seeing patients,” said a resident doctor from the orthopedic department, who declined to be named.

From the clerks registering patients to the staff involved in diagnostic work, such as blood tests and X-rays, staff said they were overwhelmed and there are far more patients than the hospital can handle.

“We work in three shifts, conducting at least 600 diagnostic tests in 24 hours,” Sanjay Mishra, head of the central pathology department, told Al Jazeera.

By 11.30am, 1,750 patients were already registered at the four counters in the outpatient department, two staff in the radiology department had conducted more than 80 X-rays, while the central pathology department – dealing with blood and sputum tests – had 105 patients on its registers. In the orthopedic section, patient number 120 was summoned. The medicine department had already administered prescriptions for 220 patients. At the gate of Nehru Hospital at BRD, many patients arrived by autorickshaw, rather than an ambulance.

This is the situation, year-round, at BRD Medical College.

In the central record room located on the second floor of Nehru Hospital, 35-year-old Suleman Khan, who is head of record keeping, sits at his desk. Files are piled all over the room.

Khan says last year, 605,226 patients visited the outpatient department while 60,891 were admitted for additional care. By July 31 of this year, the outpatient department had seen 317,555 patients and admitted 33,047 people. In the past four years, the number of patients has grown by almost one and a half times what it once was.

“Every year the number of patients is increasing. The months of August, September and October see a spike in patient intake,” he said, referring to the rainy season months.

The deaths of more than 60 children in August allegedly due to oxygen failure caused public uproar [Cathal McNaughton/Reuters]

Underserviced region

The college, named after freedom fighter and educationist, Baba Raghav Das, was established in 1969 as the state’s eighth medical college. It began with a total of 50 students and later increased to 100. Today, there are still only 100 student spots. The number of resident doctors who see the patients has marginally increased from 36 to 54, while the number of patients has increased manifold.

In a 2012 report, Professor Radhamohan Misra – a former vice chancellor of the college and convener of Gorakhpur Health Forum, a public health monitor – said that patients from 14 districts in eastern Uttar Pradesh and five districts from Bihar come to BRD for consultation.

Today, BRD is the only tertiary healthcare centre in a region of over 60 million people straddling Uttar Pradesh and Bihar. Patients from neighbouring Nepal also seek treatment there.

There are plans to upgrade the neonatal intensive care unit, but doctors in the paediatric department say it won’t be enough to keep pace with the demand for more facilities.

Last year, work on upgrading BRD began. A new medical college was inaugurated by the government of Prime Minister of Narendra Modi in July last year.

About 130km away from Gorakhpur, in the village of Khatwanian in Gopalgunj district, the Pawan family is still grieving the loss of Naitik.

Pawan was outside his house, his head shaved as part of the mourning ritual. “It is our misfortune, I do not feel like talking about it now,” he said.

“I buried my son near Chhathi Maiya (a local deity worshipped for long life for children),” he said.

“I have removed all his belongings, but his face does not go away from my eyes,” Pawan said.

His wife Rinki has not been able to come to terms with the death of her elder child; they have a three-year-old daughter Anshikha. Family members said she had grown weak due to crying.

The family is under debt due to the medical costs that have crossed 100,000 Indian rupees ($1,543).

“I will sell my two bigha (.50 hectare) land to clear the debt,” Pawan told Al Jazeera sitting inside the hut in front of his incomplete house, still without the main door.

The family is under debt due to the medical costs [Al Jazeera]

This story has been translated from Hindi into English.