Who Will Save Our Children?

Seventy child deaths on the eve of 70 years of Independence! The nation is shocked. Two doctors at the state-run BRD hospital were held responsible and removed by the Uttar Pradesh government. In its defence, the state government has been quoting statistics to prove that there has been a pattern of child deaths in Gorakhpur in August especially due to the longstanding problem of encephalitis ­ and, by implication, that it cannot be held responsible with just five months in power.While the callous corruption of these two doctors may have been the immediate cause of child deaths in this particular case, who do we hold responsible for the systematic pattern of child deaths in Gorakhpur, or in UP and the country at large? India has been the world’s largest contributor to all levels of child deaths since 1953 ­ the first year for which we have Indian data available. Starting out with nearly 4.7 million deaths a year under the age of five years (U5), it took us almost three decades to bring them down to 4 million a year.

Between 1969 and 1979 China reduced U5 deaths by 2.4 million, the highest in a decade in any country in recorded history.The beginning of the Millennium Development Goals (MDGs) did accelerate the pace of progress in India, but China again outperformed us. As did our neighbours Maldives, Nepal and Bangladesh between 1990 and 2015, to achieve their MDG targets on child survival.

We did not achieve our MDG targets, despite having a lower U5 mortality rate than our neighbours in the pre-MDG era.Maldives actually recorded the highest decline in the rate not just in South Asia, but in the entire world during the MDG period. We could dismiss the achievements of our neighbours on the ground that they are small countries. But can’t we learn from their political commitment to child survival? Secondly , what about China, whose population size is still larger than ours, and whose GDP per capita was lower than ours until 1990?
I am sure someone will jump up to say ­ China is an authoritarian country which can get things done, and is not diverse like us. Well, no one is like us as far as our commitment to child survival goes! Do we wish to continue with our uniqueness in this regard?
The story has been similar at lower levels of child survival as well. At the neonatal level (ie during first 28 days of birth), the Bimaru states accounted for 55% of all deaths in the country in 2011 ­ UP (27%), MP and Bihar (10% each) and Rajasthan (8%) ­ and 15% of the global burden. While China performed even better at this stage, with a 90% decline in number of neonatal deaths during the MDG period, we had 695,852 neonates dying in 2015 ­ more than 7 times China’s.

Clearly , with efficient and equitable health systems and doctors ­ particularly at the primary health care level ­ many of these deaths could have been averted.However, as the UP CM himself argued, in an attempt to shift responsibility to individuals, lack of sanitation was the reason for recent child deaths in his constituency . According to one report, doctors at the BRD hospital claimed, perhaps in their own bid to deflect some responsibility , 70% of children affected by encephalitis who visited the hospital were malnourished. Clearly , sanitation and nutrition are not responsibilities of hospitals and doctors ­ although they can adopt measures to mitigate some of their impact ­ and are influenced by people’s socioeconomic status, especially educational and economic status, as well as the efficacy and equity of municipalities and nutritional interventions of the government. While health systems and doctors are the immediate causes of child deaths, structural failures are responsible in the final run.

Is it the fault of parents that they are poor and illiterate ­ or that their localities are not cleaned by the municipalities?
To a degree, their own socioeconomic status could be. But even a libertarian like Milton Friedman argued for `paternalistic concern for children’ and the `financing of education’ by the government on the grounds that holding parents responsible for children `rests on expediency rather than principle’.

A state health officer in Lucknow told me in 2009 that poor people keep producing children and expect us to take care of them. Again, it is the economically and educationally weak who have more children. No matter how you approach the issue, the buck would ultimately stop at the state. Present governments have to accept their share of responsibility , but we as a nation and the Indian state since Independence are also responsible for the broader pattern of child deaths.

Social and systemic injustices have played their own set of roles. People are poor and uneducated because of both sorts of injustices. Confining ourselves to immediate medical causes is not going to take us far in addressing the systematic pattern of child deaths ­ we will have to go way beyond. If it is true that people get the government they deserve, can we, on our part, pledge that we will only vote for candidates who put forth a concrete vision for saving our children ­ the future of our nation ­ and will not indulge in social injustices that perpetuate poverty and illiteracy?

The writer leads the Health Policy Initiative at ICRIER, Delhi. Views are personal