'We Are at a Saturation Point'
Experts Blame India's Overburdened Health-Care System for High Death Tolls in Attacks

By Emily Wax
Washington Post Foreign Service
Monday, October 6, 2008

NEW DELHI -- In the frantic moments after five bombs tore through markets across the city, Rama ran to the road, cradling his 17-year-old daughter, Puja, in his arms. Blood rushed from her head. Her pulse was slow. She wasn't speaking.

His wife, who had lost vision in her right eye, pushed through the crowds, shouting, "Help us!"

"My baby girl is lost," Rama, 55, recalled screaming. "No one is coming."

Forty minutes went by before an ambulance arrived. By the time it navigated the snarled traffic to reach the hospital, 1 1/2 hours had passed and Puja had died in her father's arms.

The chubby-faced girl with long eyelashes had hoped to be married soon, said Rama, whose family, like many here, does not use a last name. Rama said Puja would probably still be alive if they had made it to the hospital sooner.

Rama's story is not uncommon in India, where 44 bomb blasts in six cities have killed more than 150 people since May. But medical experts say the toll would be lower if ambulance services and public hospitals had the resources to treat more people during the "golden hour," the crucial period after a trauma in which a life can be saved.

"In India, it should be called 'the golden four hours' since the response times tend to be slower. If we can get the patients here more quickly, we can work to save them. We have to learn to live with terrorism and do better," said Mahesh C. Misra, chief of trauma surgery at the All India Institute of Medical Sciences in New Delhi, considered one of the country's best public hospitals. "Ambulances are not sufficient. Public training in CPR is not there. And there are huge disparities in health care in smaller cities."

Public outrage over the bombings has focused largely on poor police investigations and the government's inability to prevent attacks. But an equally pressing problem is the overburdened health system, according to surgeons, emergency response experts and others frustrated by India's trauma services.

In New Delhi, for instance, there are 35 working public ambulances with life-saving equipment to serve a population of 14 million, according to the capital's government.

Attacks in major cities occur almost weekly, often targeting areas with heavy traffic, such as bus stops, amusement parks and shopping bazaars. The bombings usually result in high death tolls, mainly because more than half of those injured do not receive prompt medical care, experts say.

"We have to combat terrorism not only with security or policies, but with our hospitals," said Ashok Randhawa, president of the Sarojini Nagar Mini Market Traders Association. Randhawa's best friend died in an attack in October 2005 that killed 50 others and injured 155.

"We all wonder if he and other loved ones could have made it if the care was better," Randhawa said. "That pain haunts us."

The bombings and high death tolls reveal widespread cracks in India's public health-care system, especially in smaller cities and rural areas.

In Jaipur, where near-simultaneous blasts in May killed 80 and injured 200, the main government-run medical center did not have a working blood bank. Nor were there enough workers to help with the emergency. Puddles of urine and blood collected in the halls. There were not enough beds for the victims, so many stretched out on the floors, attended by relatives. Stray dogs wandered the halls and napped under cots.

"It's simply a nightmare," said Manoj Krishna, a teary-eyed doctor who was standing outside the hospital, his lab coat stained in blood. "We can barely handle our patients as it is. We are at a saturation point. We weren't prepared for this."

India's health-care system is inequitable, despite the country's recent economic growth. More and more foreigners come for heart surgeries or hip replacements in private hospitals that offer personal rooms and butler service. But public hospitals are sometimes so strained that patients have to share beds. Many are forced to ask relatives for money so that they can shift to private hospitals for access to CT scans or dialysis machines.

India spends 1 percent of its gross domestic product on public health, far less than other countries with similar per capita incomes. The United States spends about 16 percent of its GDP on public health care.

From the new trauma ward of his New Delhi hospital, Misra said there is a lack of such centers nationwide and a pressing need for more ambulances. Paramedics also need better training, he said. He has sent teams of staff members to Israel for CPR training and for lessons in rapid emergency response to attacks.

"In Israel, even 16-year-olds know what to do to lift patients, to give first aid," said Misra, who is hosting a conference next month in New Delhi on prompt trauma care. "I think India will have to go that route if these blasts continue."

Within two years, officials in New Delhi plan to add 450 ambulances to the city's fleet and a motorcycle first-aid team, with 25 experts who will be able to weave through traffic. India's government also plans to build trauma units along highways to reduce the number of traffic deaths caused by slow emergency care.

But for many, the changes will come too late.

In a crowded ward at Dr. Ram Manohar Lohia Hospital in New Delhi, Rama rested on a cot, sweating under ceiling fans. One arm was in a cast, and his legs -- which suffered shrapnel wounds in the Sept. 13 attack -- were bandaged.

Rama wept as he took out two passport-size photographs of his daughters.

One showed Puja in a sparkly sari and red lipstick. The other was of Santosh, 22, who was injured in the blast and is in a coma.

"I just wish we had gotten here sooner," he said. "Maybe Puja would be by my side."