Public Health at the Kumbh Mela

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The Times of India Highlights HSPH Team’s Findings

Read the full article here: “Harvard doctors give Kumbh Health Facilities thumbs up”

How the deadly stampede outside the Kumbh Mela could have been avoided

– Logan Plaster

http://qz.com/52805

Ephemeral Hospitals, Enduring Insights: Healthcare at the Kumbh.

– Dhruv Kazi , MD, MSc, MS

 

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Savitri Devi, a 57-year-old mother of two, began her journey to the Mahakumbh in a small village in the Indian state of Madhya Pradesh. She traveled 12 hours by train with her husband in order to take part of Hinduism’s most spectacular celebration, a bathing ritual performed by millions at the confluence of India’s holiest rivers.

This Kumbh is arguably the largest human gathering of all time, swelling to 30 million on the holiest day of the festival, and totaling to as much as 100 million over the course of the entire 55-day event. By those estimates, if the Kumbh were a nation, it would be the 12th most populous in the world.

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Delivering health care to 100 million people is an enormous task anywhere, but it’s even more challenging when the city – and hence its hospitals – must be temporary. By the end of March, the entire city will have been dismantled. By the time the monsoons arrive, almost the entire area of the Kumbh will be reclaimed by the rising rivers.

Ten sector hospitals are constructed specifically for the Mela. Each of these clinics comprises a collection of large tents that house an outpatient clinic and a 20-bed inpatient unit. The hospitals operate 24/7 throughout the duration of the festival, though workload peaks with population surges around the most auspicious bathing days. Each day between 500 and 800 patients arrive and are seen – briefly – by one of the physicians on duty. These doctors come from government clinics from around the state and are assigned to the Mela for two months apiece. The doctors work in 8-hour shifts, have no official days off, and sleep in tents that are pitched adjacent to the clinic. Each hospital has a pharmacy with over 90 drugs that are provided free of charge.

The centerpiece of this healthcare delivery system is the central hospital in sector 2. Here patients can be seen by a range of specialists, including orthopedics, surgery, and obstetrics. There is a 100-bed inpatient unit and a 2-bed ICU. Diagnostic tools such as X-ray, ultrasound and electrocardiograms are available. Dr Srivastava, who supervises the entire healthcare delivery system of the Mela is based here, and receives daily reports on the number of patients seen at each of the smaller sector hospitals.

Connecting these hospitals is a fleet of more than 100 ambulances which are responsible for transferring patients who need specialized care from the sector hospitals to the central hospital. The ambulances, like the doctors who staff the hospitals, have been drafted from community health centers across the state. Each ambulance arrives with its own driver, who is then provided with accommodation at the Mela. The drivers, who receive no additional training for the Kumbh, seem to take great pride in their work. I had the opportunity to meet with Arvind Kumar, a 40-year old from Ajamgadh, who has been at the Mela for a month. He proudly showed me his log – a detailed record of trips made (including point of origin and destination), distance traveled, and fuel costs. There were no patient records in the ambulance loArvind Kumar, Ambulance Driver in Sector 2.

Arvind Kumar, Ambulance Driver in Sector 2.

Arvind Kumar, Ambulance Driver in Sector 2.

Ambulances stationed at Central Hospital.

Ambulances stationed at Central Hospital.

The ambulances themselves appear to be new and well maintained, with clean stretchers to transport patients and a hand-held radio device for communicating between ambulances and with central dispatch. Each ambulance carries an oxygen tank, a host of emergency medications, and four disaster kits: for drowning, burns, bomb blasts and stampedes. It is evident that a reasonable amount of thought has gone into designing each of the kits, but there are no paramedics (which is typical in India) and a physician must accompany seriously-ill patients. Based on an examination of  Arvind Kumar’s log book, it appears that an ambulance makes 5-6 trips a day.

Every Ambulance at the Kumbh has a Stampede Kit.

Every Ambulance at the Kumbh has a Stampede Kit.

So what does an interdisciplinary team from the Harvard School of Public Health have to contribute to an ancient congregation of millions of pilgrims which seems to be running remarkably smoothly? The answer is simple: Data.

During our visits to the hospitals, we noted that the doctors manning the outpatient posts see up to 800 patients a day – and many times that figure on bathing day – and are clearly overstretched. Lines of patients preclude even a cursory medical examination. No vital signs are documented and there are no stethoscopes in sight. On the other hand, inpatient units were almost uniformly unoccupied. Row after row of hospital beds, neatly folded red blankets, and I.V. poles stand untouched. On our visit two days before the peak bathing day, we saw only the occasional hospitalized patient – a testament to excess capacity in the system.

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This striking contrast between the excess capacity on the inpatient side and extreme shortage of manpower on the outpatient side is the result of an information vacuum about the disease burden and clinical resource utilization in this patient population. Poor data result in poor planning, and ultimately a lopsided distribution of resources.

Our team’s work begins to address this critical gap. By digitally capturing patient encounters at four sector hospitals, we are mapping healthcare delivery at the Mela. We have three broad objectives in doing so.

First, we want to show that it is feasible to use low-cost technologies to gather quality data in a resource-scarce setting. The fieldwork for the project is being done with a small team of passionate (and remarkable) students wielding a handful of iPads. If we can do it, the government certainly can too.

Second, by providing a snapshot of the healthcare needs of the attendees, we hope to help optimize resource management. For instance, knowing that less than 1 percent of outpatients get admitted to the hospital would suggest that the most cost-effective strategy in the future would be to station more physicians in outpatient clinics and offset the costs by planning for fewer hospital beds at sector hospitals. The reserve capacity needed for epidemics should be centralized at the district hospital.

Third, and most importantly, real-time analysis of the data provides an effective surveillance tool – an early warning system for impending epidemics. This is no easy task in a setting such as this where the population at risk – i.e., the number of pilgrims at the Mela – varies greatly from day to day. When analyzed methodically, differences in patterns of disease between hospitals and over time can help distinguish a signal of an epidemic from the noise of random variation. This tool can  help public health officials deploy preventive strategies in a timely manner to avert a a widespread outbreak.

Conventional wisdom holds that generating quality data in resource-scarce settings is prohibitively expensive in resource-scarce settings, and that ad hoc planning is therefore unavoidable. By collating and analyzing data from over 20,000 patients, we are turning that assumption on its head.  Although the entire Kumbh Nagar (township) will have been dismantled by the end of March, the insights we gain from the analysis of the data will endure. With the support of the Harvard School of Public Health and the FXB Center for Health and Human Rights, we hope to empower future Kumbh organizers with the information they need to cost-effectively safeguard the health and well-being of the millions who will follow in Savitri’s footsteps for generations to come.

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View from Shastri Bridge: Crowds Begin to Increase Rapidly as the Kumbh Prepares for the Most Auspicious Bathing Day.


In the Aftermath of the Stampede

– Satchit Balsari, HSPH Kumbh Mela Team Leader

February 11, 2013

It’s 1:30am and we are now in Benaras.  We delayed our morning departure to spend another day at the Kumbh.

Mauni Amavasya was not the uneventful day the organizers had hoped it would be. Officials say that 30 million people (one and a half times Bombay’s population) took a peaceful dip at the Sangam. Hundreds of thousands of pilgrims lined Parade Road to watch the processions roll by – the Naga sadhus, the Shankaracharyas, and the mahants, from Hinduism’s various denominations, and from India’s far flung corners. There were people everywhere – on the pontoons leading up to the Sangam, on the pontoons bringing them back safely after they holy dip, on Triveni Road, and Jagdish Road and Mahavir Road and every road that intersected every other road in the Nagri, on the hill next to the Sangam, inside the Akharas and outside the Akharas, on Shastri Bridge that spanned the wide Ganga, on the roads that led to the Nagri, on the roads that led away from Allahabad, on the 6000 buses waiting to depart from the seven bus stations, in the Ganga, in the Yamuna, in the Sangam and besides the Sangam. And on a footbridge over platform 6 at the railway station. It was the world’s biggest fair. Everyone was invited. And everyone came.

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The atmosphere was festive: the energy palpable, the excitement contagious, and the masses patient. Men, women, children, the elderly and the frail all headed to the Sangam. There was color everywhere: bright reds and greens and yellows and oranges. On the turbans, on the sarees, on the flags, on the walls. And there were songs: incessant, loud and mostly pious. And smells: of incense, and prasad and marigolds and humanity. And the millions walked to the Sangam with a purpose. They were resolute in step, but not hurried; they were carefree but cautious. They were happy. They were accommodating. They were joyous. The sight from 30 feet atop the watch tower at the Kumbh was one to behold:a dense, teeming mass of Snaanarthis (bathers), punctuated by billowing bright sarees drying in the wind. Bathers frolicked in the water. Commuters lounged where they could. Villagers tried to sell their cows for Godaan. The otherwise demure Indian homemakers stripped down to their petticoats to bathe in the river. The sadhus sat atop tractors and chariots and colorfully decked lorries. Commerce flourished. Sins perished.

It was indeed a beautiful day in Prayag. As it has always been for centuries when the Mela arrives at the Triveni Sangam. Except in 1954 – when a rogue elephant barreled into a dense crowd that had gathered to see their beloved Prime Minister Jawaharlal Nehru. The ghost of the resulting stampede has loomed over the Allahabad Kumbh ever since. No Mela adhikari, no Kumbh sevak, no politician, no government servant, no Allahabad nivasi wants another mishap at the Kumbh.

The sun was slipping behind the tent-tops. Everyone breathed a sigh of accomplishment, of satisfaction, and of relief. Another big bathing day had come and gone. And millions had been returned home safely. Almost.

The large notice board in the railway booking office compound in Sector 2 of the Kumbh Mela had 202 train options for people to choose from. Late last evening, when the Rajdhani arrived, thousands of eager commuters rushed up the sole footbridge from platform 1 to platform 6. Police tried to hold back the crowd. Some say a lathi (baton) may have been raised. No one really knows what happened, whose foot slipped first, who toppled next. But several hours later, when the last ambulance pulled by at SRN Hospital at 2:30am, 36 pilgrims were dead, over thirty injured. Three were in critical condition.

Two nights ago, a journalist from one of the world’s leading dailies was lamenting how hard it was to report on the Kumbh. That millions had gathered in India once again for a holy dip in the Ganga wasn’t new. Wasn’t captivating. Wasn’t interesting. The government’s worst nightmare had just come true: the Kumbh had suddenly become interesting.

“Horror at Kumbh” screamed the headlines in one of India’s largest dailies. And we, the HSPH Public Health team, shared the organizers’ disappointment, heart-break and dejection.

Thousands of people work for months on end to make the Kumbh Mela a success. The statistics are staggering, and yet, the Indian bureaucracy, sometimes fatalistic and often times laissez-faire – puts its muscle behind the Kumbh. The Kumbh Mela sees more resources, more planning, more implementation and more goodwill than any other large public project in India. It is tempting, very tempting, to therefore attribute the footbridge stampede to a freak but unfortunate accident that may scar the 2013 Mela forever. But to do so would be erroneous, for we believe that the footbridge accident is a symptom of a more pervasive malaise in the planning process, not unique to the Kumbh. The dismissive, overconfident, exclusive, hierarchical, rigid planning processes so rampant across institutions in the region, are as responsible for the foot-bridge stampede, as they are for the bottlenecks from the main avenues to the pontoon bridges, for hundreds that get traumatized every day running from pillar to post to search for their lost relatives at the Kumbh, for the thousands that get prescribed medications without so much as a cursory glance from their physician and for the oxygen tanks in the ambulances that can’t be unlocked without a key.

We will write more about these and related issues in the coming days.

A child propped up on the Lost and Found dias, waiting for his parents to spot him.

A child propped up on the Lost and Found dias, waiting for his parents to spot him.

India Today Interviews Kumbh Mela Team

Read the full story here: http://indiatoday.intoday.in/story/2013-maha-kumbh-mela-public-health-research-harvard-university-india-today/1/249649.html

NYTimes Blog Highlights HSPH Research Project

Click here for the blog post: http://bits.blogs.nytimes.com/2013/02/08/can-big-data-from-epic-indian-pilgrimage-help-save-lives/

Counting Down to the Biggest Bathing Day Yet

Allahabad medical students input medical records from Clinic 4 into the custom iPad app.

Allahabad medical students input medical records from Clinic 4 into the custom iPad app.

Barricades on the edge of the Kumbh, designed to slow down foot traffic heading towards the Ganges.
Barricades on the edge of the Kumbh, designed to slow down foot traffic heading towards the Ganges.

India’s regional emergency call number is well advertised at the Kumbh.

India’s regional emergency call number is well advertised at the Kumbh.

The sector clinic’s ICU is prepped and ready.

The sector clinic’s ICU is prepped and ready.

The crowds grow exponentially in the day leading up to the holiest bathing day.

The crowds grow exponentially in the day leading up to the holiest bathing day.