June 2, 2023, was a sad day, globally. Three trains crashed into each other in the eastern Indian state of Odisha. As of June, the triple train accident has led to 288 deaths and 1,100 injured people, making it the most significant such casualty of the decade. The aftermath has been further tragic. There have been instances of unidentified bodies, those with physical and mental trauma left without much support in overburdened hospitals, and even a rare case of a victim “rising from the dead” as the “body” was incorrectly labeled for dispatch to the morgue. All such reports point to a tragic state of the public health system.
The main tragedy is: a fragmented health system attempting to play catch up with emergencies. Ideally, the health system across India could have been prepared to deal with the aftermath of such an accident. The COVID pandemic was the most recent health emergency drawing everyone’s attention to public health. This resulted in new financing for healthcare. Among other things, India saw a scale-up of testing and a globally hailed vaccine drive made possible due to health funding gains. However, most initiatives and funding drives were COVID-specific. The chronic workforce shortages, infrastructural challenges, lack of solid regulations for the private sector, and disparities across regions and populations continue to be the same. Had the attention been toward the strengthening of a decentralized health system, India wouldn’t have tackled just one health emergency but ensured a strong defense against future emergencies including the aftermath of the triple train accident. Resources were mobilized promptly. However, ideally, this should not have been required. The local health systems should have had adequate resources and an emergency preparedness action plan. Let’s focus on two examples of neglected health system aspects – surgical care and mental health care – though many others exist.
The second tragedy is the limited surgical care capacity to deal with physical trauma, injuries, and mass casualty in emergencies. The hospitals in the region were overburdened with limited staff and resources to manage injuries while the local communities demonstrated solidarity. Conducting infection-free procedures for severe injuries, having adequate and safe blood supply for transfusions, ensuring pain-free perioperative care, directing efficient triaging, and dealing with complications on the go are crucial components of surgical care service delivery that need to happen on an emergency mode in a scaled-up way in such scenario. This can only happen if enough surgery-providing facilities are well-distributed across regions that can be reached in time. Ambulance availability, emergency dispatch, and triaging systems are critical for avoiding life-threatening delays. These facilities should be staffed with adequate number of well-trained surgeons, anesthetists, nurses, and other healthcare workers with access to pain medication, blood products for transfusions, necessary tools, etc. Finally, the surgical care delivery system has to ensure that the care is free and does not further burden those devastated by the emergency. Put together, timely access, infrastructural and workforce capacity, high-quality care, and financial risk protection in the context of surgical care should be integrated into emergency planning, health system strengthening, and broader health policymaking. Surgical care in India faces challenges for all the above-mentioned expectations. India does not have a national surgical plan that could be a first step toward solving the tragedy.
The third tragedy is the unmet mental health care need arising during and after such emergencies. Exposure to accidents involving mass casualty puts victims in danger of mental health distress. Dealing with physical pain due to injuries can exacerbate mental health problems. Witnessing mass casualty and being forced to deal with the death of near ones can worsen mental health in the short and long runs. Particularly vulnerable are children and adolescents who can suffer life-long negative impacts. Healthy people might develop mental health issues including post-traumatic stress, depression, and anxiety for the first time. While those with pre-existing conditions are at an increased risk for exacerbation or resurgence of symptoms. Continued post-traumatic stress, anxiety, grief, helplessness, hopelessness, and irrational fear can worsen the overall health and productivity of victims. The issues can evolve in complex ways over time starting from survivor’s guilt going to substance dependence, and self-harm ideation and behaviors. While different in their manifestation, several problems mentioned above witnessed a rise during COVID. Once again, broader systemic preparedness to deal with public health issues is the key.
Managing mental health in a disaster should not be reactionary. Instead, the approach should rely on – readiness, response, relief, rehabilitation, recovery, and resilience. It should be rooted in decentralized mental healthcare integrating local communities. Mental health first aid and continued psychosocial support and monitoring of victims are highly important. Support should also be extended to those who were indirectly impacted through loss of family or friends. To cater to all such mental health issues, the country needs a holistic and well-resourced system in place including community groups, primary care, and institutionalized care. While policy and legislative focus on mental health have improved in India in the last decade, investments have been limited. Further, the on-ground implementation of the district mental health program has faced challenges leaving large coverage gaps. Scaling up mental healthcare with a focus on equity is essential.
A fundamental transformation in tackling health emergencies is needed. Systemic resilience trumps reactionary mobilization. Looking at isolated health problems should be replaced by working on integrated health solutions.
About the author: Siddhesh Zadey is a cofounder of the non-profit think-and-do tank Association for Socially Applicable Research (ASAR) India, a global surgery & alcohol use researcher at the Global Emergency Medicine Innovation and Implementation (GEMINI) Researcher Center, Duke University US, and an Adjunct Research Faculty of Dr. D. Y. Patil Medical College, Hospital, and Research Centre, Pune, India. He is the Chair of the G4 Alliance Working Group for SOTA Care in South Asia and serves on the State Mental Health Policy Drafting Committee for the Maharashtra state in India.
Competing interests: None
Handling Editor: Neha Faruqui