Kafeel Khan. The Gorakhpur Hospital Tragedy: A Doctor’s Memoir of a Deadly Medical Crisis. Pan Macmillan India, Delhi, 2021. 300 pages, INR 219.86 (paperback), INR 208.87 (Kindle), ISBN: 9789390742714

This book is a first-person account by a young paediatrician in Uttar Pradesh, India, who was involved in helping save lives in a massive hospital tragedy in 2017. It was precipitated by the lack of oxygen supplies, killing 63 children and several adults [1]. The doctor was made the fall guy by the state and put through grave injustice.

It is five years since the Gorakhpur hospital crisis of August 2017. The government-run BRD Medical College and Hospital in Gorakhpur, in Eastern Uttar Pradesh, is said to have run out of liquid oxygen, mainly in the neonatal and encephalitis wards, due to stoppage of oxygen supply after non-payment of pending dues. This sudden scarcity of oxygen late in the evening ostensibly resulted in several deaths among the sick newborns and other children and adults over the next 48 hours [2]. Investigations into the cause of the disaster have still not been concluded, though most of the accused were released on bail within a few months, and no one has been held guilty of the unnecessary deaths. One only hopes that the systemic issues that led to this crisis have been remedied, and that such a crisis is not repeated.

The painful detailing of what this doctor went through makes for sobering reading. I have every reason to surmise that Kafeel Khan, the protagonist, was a sincere and friendly paediatrician, from an elite background in Gorakhpur, and acted in the true spirit of medicine when he rushed to the hospital to help on that fateful night in August 2017. Lauded initially by everyone, he was later pilloried as the major cause of the crisis. It seems that the doctor fell prey to a communally and politically charged situation where his well-known flamboyance as well as his religious affiliation worsened the situation for him. While several people were initially charged, all including Kafeel Khan have been released on bail, and all except Kafeel have resumed their professional duties. Khan was denied re-instatement, and has in fact been dismissed from his permanent employment on grounds unrelated to the initial complaint of negligence and corruption. It appears that his dismissal from employment was largely on the charge of carrying on private practice while serving in a public hospital. Since, the judicial process is still on, this review is only an opinion on the doctor’s version of what happened, and not a comment on the entire saga.

If we assume that what is detailed in this book is true, the entire saga of the 2017 oxygen supply crisis reveals the rot in our society, governance and judicial processes; and in particular, how our health systems operate at a medical college and at tertiary care level. It seems everything that can go wrong went wrong. At the level of the tertiary care hospital, where clinicians and doctor-administrators worked together, pervasive corruption, apathy towards clinical emergencies, not standing their ground before the political and administrative leadership, and complete lack of crisis responsiveness were on display.

The book alludes to some technical issues, which I find intriguing as a paediatrician. How can children who are on high settings on ventilation be helped by bagging with a self-inflating ambu bag without supplemental oxygen? Why did the doctors on call in those dire times entrust hand-bagging with an ambu bag to the hapless parents? Could they not summon other doctors, or nurses from other departments than their own, or even medical and nursing students from their hostels? Some other clinical practices mentioned by Kafeel Khan are no more standard of care but were in place in Gorakhpur. I am sure care practices always have scope for improvement.

Who was responsible for deaths of so many newborns, children and adults?

If we look back at the processes over the last five years since the disaster, it seems that this question of responsibility was buried under assertions and allegations for some time, and then things returned to “normalcy” and the primary question was forgotten. At various points in time, assertions were made in media reports that there was no shortage of oxygen, and that the primary illness for which the children were admitted resulted in so many excess deaths, also that behind this was a political conspiracy to malign the government in power.

It is important that we fix responsibility, but we need to go beyond that. We need clear headed analysis of where and why we got it wrong. Finally, after such a public health crisis, we need to accept responsibility, both as individuals and as systems, for the mistakes made, if we are to learn from them.

There are larger issues of responsibility, accountability and ethical conduct. Why do elected representatives and civil servants function the way they do? If financial corruption is the besetting evil of public systems in India, incompetence, laziness and bloody-mindedness are not far behind. Why are these acts of omission and commission never identified as such? Why is responsibility never fixed and punishments delivered, at responsible decision-making levels?

Some other questions that bother me: Can ethical conduct be taught? Is this something to be left for individuals to figure out on their own? When we address the question of reform in public systems, can we not also address the question of reform in human nature? Is that too much to ask, or even hope for?

The account in this book bothers me for another reason. It seems plausible that Dr Khan was victimised because he became prominent and a hero in the media. Since this was akin to being an external whistleblower, it irked the people in power. Even though we have a law that protects whistleblowers, it is seldom of use. And whistleblowers often suffer, as the protagonist in this book suffered the loss of employment.

One reason mentioned for this dismissal from his government job was that he was engaged in private practice. It is an open secret that most clinicians in the public hospitals and medical colleges in most states including Uttar Pradesh, indulge in private practice, and the authorities choose to ignore that. But this illegal activity can be used against you in a confrontation with the state to which activism may lead you. This should serve as a lesson to all those whose struggles involve combating the state, that one should be mindful of all wrongful practices, howsoever minor, lest they be used against you.

Finally, it seems no one was responsible for the ghastly oxygen crisis and the deaths that ensued. And the protagonist in this book, Dr Kafeel Khan was found to be the perfect scapegoat to be blamed and punished. Lack of accountability of systems was complicated by injustice to the vulnerable.