To Be Poor and Sick in India

MUMBAI — I first became interested in India's government hospitals after my son was born last May at Breach Candy Hospital in Mumbai, one of the city's well-regarded private hospitals. The care was exceptional, but a stay at a private hospital is a luxury that only a small percentage of Mumbai residents can afford. My curiosity about what kind of care existed for the city's less fortunate babies led me to write about the fight against infant mortality in the Dharavi slum for India Ink in September.

But India is larger than the metropolises of Mumbai and Delhi, and the people living in Dharavi are luckier than most. So in digging deeper on the subject of health care, I traveled with a photographer, Sami Siva, to West Bengal, Gujarat and Andhra Pradesh, visiting hospitals and speaking with caregivers, government officials, patients and academics along the way.

What I found is that the health care that lower-income patients receive is not only problematic on the whole; it can sometimes be outright lethal. In a series that will run through Thursday, I examine the complex issues facing India's government hospitals and health care in greater detail.

India's massive population, it would seem, is the largest obstacle to running an efficient state health care plan for the poor. At every stop in the investigation, themes of overcrowding, overworked medical staffs and failing equipment dominated conversations. At smaller rural primary health centers throughout India, the doctor-to-patient ratio can be as high as 75,000 to one, according to the doctors who work there.

Not only are those numbers untenable, they add instability to larger hospitals nearby. When a primary health center in a village cannot adequately sustain a patient's life, the patient will then be dispatched to a university hospital in the region. That hospital may be receiving patients from as many as 10 or more other areas with overstretched primary health centers.

And when that university hospital can no longer handle that patient load, the same emergency care patients are then dispatched to larger, urban hospitals, some of which are as far away as the other side of the state.

Meanwhile, state governments shy away from the difficult task of delivering meaningful care to their poor. The leading answer to health care reform for the poor has most commonly come in the form of yojanas, or public-private partnership insurance programs for people living below the poverty line. States that have adopted such large-scale yojanas in recent years include Tamil Nadu, Karnataka, Andhra Pradesh and Gujarat. But critics say that these plans merely relegate patients to the very government facilities that are already failing them.

C.A.K. Yesudian, professor and dean of the Tata Institute of Social Science's School of Health System Studies, said most government plans were a political posture, rather than a permanent solution to India's health care woes.

"Every state has one, but they have no meaning," Mr. Yesudian said. "But the poor either don't know these things exist, or they get turned away from medical care when they do go the hospitals."

It is common for people to be denied care in state hospitals because of the nature of an ailment or because of patients' caste, class and religion, despite the right to such services being guaranteed by the laws of Indian states. Patients with infectious diseases like incurable tuberculosis or H.I.V. are sometimes refused treatment, particularly in rural regions of the country, where underequipped or undereducated staff members are frightened of getting infected. Not only does this kind of behavior defy the ethical standards of the medical practice, but it delays the treatment these patients need to survive.

Poorer patients are more reluctant to trust government hospitals because of their reputation for class discrimination. Often, these fears lead patients to receive care locally and from people without proper training, who may further complicate serious medical conditions.

On Tuesday, the series begins in Kolkata, where an urban children's hospital is haunted by a series of infant deaths that may have originated not from malpractice or neglect, but from the failing infrastructure of rural West Bengal's primary care centers.