‘Absence Of Emergency Care Law Is Costing Lives In India’
India needs a universal access number, akin to the US's 911, which integrates police, fire, and medical services, simplifying the process and saving valuable time, says Piyush Tewari, founder and CEO of SaveLife Foundation
Mumbai: In 2022, India reported over 460,000 road accidents, leading to 168,000 deaths--about one death every three minutes, on average. This is the highest number ever recorded. Further over 440,000 people had non-fatal injuries, according to data from the Ministry of Road Transport and Highways. A third of the accidents were on national highways, about a quarter on state highways and the rest on ‘other roads’, corresponding to 36%, 24% and 40% deaths, respectively. Two in three victims are in the 18- to 45-year age-group, while 83.4% of fatalities occur in the working age population of 18 to 60 years. Urban areas accounted for 32% of road accident deaths, while rural areas had 68%, reflecting challenges such as insufficient trauma care facilities and limited awareness of road safety measures.
Piyush Tewari, Founder and CEO of SaveLIFE Foundation (SLF), has dedicated himself to reshaping road safety in India since 2008. Prompted by personal tragedy--an incident that claimed the life of his young cousin in a road crash--Tewari embarked on a mission to address the alarming statistic of over 1 million road accident deaths in a decade, with half attributed to a lack of timely care. Tewari’s and SLF’s efforts led to the enactment of the Good Samaritan Law in 2016, which fosters a culture of assistance and protection for those aiding crash victims.
As India contends with a high number of accidental deaths, particularly due to road crashes, Tewari emphasises the pivotal role of legislation in establishing uniform systems and standards, drawing parallels with the Right to Education Act, as India seeks to ensure accessible and standardised emergency medical care nationwide.
Edited excerpts from an interview:
SLF has recently released a report on statutory rights to emergency medical care, studying the laws in 10 countries including India. Could you tell us more about the report?
SaveLife has been examining the state of trauma care in our country, recognising the intricate systems involved in saving lives. These encompass everything from calling for help, bystander care, ambulance services, and hospital care. While these components exist in our country, they often operate independently rather than as a cohesive chain.
To understand how other countries have successfully integrated these subsystems, we collaborated with the Thomson Reuters Foundation and the Trust Law network. Four global law firms conducted the study, focusing on countries with diverse income levels and populations. Our findings are categorised into two parts: the presence of legal frameworks for emergency medical care and the existence of corresponding on-ground systems.
For instance, developing countries like Brazil, South Africa, Malaysia, and Pakistan have statutory clauses ensuring emergency medical care. Similarly, developed countries like the US and Germany have both statutory rights and established systems. In Australia, we noted partial written rights, leaving some aspects to be defined by existing systems.
In the case of India, while there isn't a specific legislatively backed right to emergency medical care, judgments from the Supreme Court have interpreted it as a fundamental right under Article 21 of the Constitution--right to life and liberty. Our report details these findings, including the legal statutes used by these countries.
An intriguing case was Japan, where a robust on-ground emergency medical care system exists despite limited written statutes, resembling Australia. However, the contrast between the strength of the system and the written statutes is more pronounced in Japan than in Australia.
The report highlights the existence of the Good Samaritan Law in India, but it suggests that there is room for improvement. Could you elaborate on the specific steps that can be taken to make this intervention more effective?
In 2012, the SaveLife Foundation initiated legal action by approaching the Honourable Supreme Court of India, citing instances where injured individuals on the road lacked medical assistance from bystanders. A deeper investigation revealed that the issue wasn't simply public apathy but, in many cases, a profound fear of legal entanglements and procedural hassles.
After filing a petition in 2012, the case spanned four years, culminating in a significant development on March 30, 2016. The Honourable Supreme Court, utilising its powers, established the Good Samaritan Law, offering fundamental protection from legal and procedural challenges. This included shielding Good Samaritans from police questioning, forced disclosure of personal information, hospital detentions, payment obligations, and prolonged court procedures.
This judicial decision eventually translated into law. In 2019, the government of India, as part of the Motor Vehicle Amendment Act, introduced a section to ensure protection for Good Samaritans. However, a gap has surfaced since 2019--although the statute declares protection from various legal and procedural challenges, it lacks a grievance redressal mechanism in case a Good Samaritan faces harassment.
The primary area for improvement is the incorporation of a grievance redressal mechanism under Section 134A, related to the protection of Good Samaritans. This mechanism should be implemented by either the Union or state governments, offering relief to Good Samaritans in cases of non-compliance by police or hospitals.
The second crucial area involves expanding the scope of Section 134A. Currently limited to traumatic injuries in road crashes, it should be extended to cover all forms of trauma, including violence, with a specific focus on violence against women.
The third imperative is to address the lack of awareness about the existence and details of this law. The state and the Union must undertake widespread awareness campaigns to inform the public of their rights, enabling them to use the law effectively in saving lives, protecting the injured, and defending themselves against potential issues with authorities.
Moreover, acknowledging the hesitation in cases of violence, especially against women, the Good Samaritan Law should be more inclusive, creating a system friendly to those willing to assist victims. Expanding the law to cover various forms of injuries is essential for its comprehensive effectiveness.
The report mentions various aspects of emergency medical care, such as ambulance protocols and funding mechanisms. What were the most significant challenges or gaps identified in these areas, particularly in the Indian context?
Let's begin by addressing a critical issue in our emergency medical services--the confusion regarding whom to call in the event of an injury. The multitude of numbers (100, 108, 102, 101) creates confusion for the public. To streamline this, India needs a universal access number, akin to the US's 911. While 112 has been introduced, it should integrate police, fire, and medical services, simplifying the process and saving valuable time.
Concerning ambulances, a recent report highlights significant gaps--over 70% transport bodies, many lack essential equipment, and there are issues with staff training. Standardising ambulance services and enforcing these standards at the district and state levels are crucial. Additionally, instituting a prior notification system for hospitals is necessary for effective trauma preparation.
Upon arrival at the hospital, a systematic triaging process is vital. Ensuring an active triaging desk directs patients promptly to the required care (Operation Theatre, Red Bay, Green Bay) and follows established care protocols. While some services exist, such as the 108 Ambulance Service, they often operate disjointedly from the hospital system, emphasising the need for an interconnected and streamlined chain of services.
Recognising these gaps, there's a compelling need for a ‘right to trauma care’ law in India. Such legislation would provide a framework to unite and optimise various elements within the emergency medical services chain.
The study recommends the introduction of a ‘Right to Emergency Medical Care Act’ in India. Can you explain how such a law could improve the current state of emergency medical care?
Firstly, the preamble of the law must explicitly emphasise that trauma care is essential for preserving the right to life, as it is time-sensitive and crucial for preventing loss of life. This ensures that the law explicitly guarantees trauma care as a fundamental right under the constitution.
Secondly, the existing disjointed systems and the absence of necessary systems must be addressed. Drawing parallels with the Right to Education, the law should serve as a catalyst for identifying areas of improvement, prioritising actions, allocating budgets, and creating the required infrastructure. While it may not be a silver bullet, the law can initiate a discourse and contribute to building a more comprehensive system for trauma care in the country. This approach aims to trigger action, much like the impact of the Right to Education law, by addressing the traditionally missing elements and fostering a deeper discourse on the necessary systems for effective trauma care.
The report says the implementation of state-specific referral system guidelines is opaque in India. What challenges have you identified in ensuring the effective implementation of these guidelines, and how can transparency and accountability be improved in this regard?
Firstly, it's essential to note that, as per the Patient Rights Charter issued by the National Human Rights Commission, all patients possess the right to proper reference and transfer to the necessary facilities. However, effective implementation hinges on states developing specific protocols.
These protocols should address key aspects, including the establishment of inter-hospital transfer agreements, the implementation of communication systems between hospitals to facilitate informed and prepared acceptance of referred patients, and the creation of a physical transportation system to ensure seamless transfers. In some instances, states utilise the 108 ambulance service for transfers between government hospitals, but it is crucial to extend these mechanisms to include competent private hospitals when needed.
Several states, including Tamil Nadu and Uttar Pradesh, have taken steps by formulating guidelines for patient referral. Additionally, Karnataka has introduced an online referral system. However, the focus must shift from guidelines to comprehensive system development. While certain states have made progress, it is imperative to establish the necessary systems for a smooth and effective referral process, ensuring the survival of victims or injured individuals being transported between facilities.
How effective is India’s current framework for emergency medical care?
Healthcare being a state subject, states independently tackle emergency medical care concerns. For instance, Gujarat was among the first states to enact an Emergency Services Act, formalising ambulance services and setting standards. However, the focus tends to be unilaterally on ambulances, neglecting what transpires before and after the ambulance stage.
In terms of legal frameworks, the current landscape lacks a dedicated legislative framework for emergency medical care. Instead, various Supreme Court judgments, like Pearlman Katara vs Union of India (1989) and Paschim Banga Khet Mazdoor Samity vs State of West Bengal, obligate the state to ensure timely medical treatment. Unfortunately, these judgments lack specificity on how systems should interact and operate at the required quality for the provision of life-saving medical treatment.
Existing regulations, such as those from the Indian Medical Council (now the National Medical Council) on professional conduct and ethics, mandate physicians to provide emergency care. Additionally, the Clinical Establishments Act of 2010 outlines registration and continuity requirements for emergency wards and medical protocols. However, implementation remains a challenge, with many states yet to adopt or enforce the Clinical Establishments Act.
While there is evident intent from both the judiciary and the government to address these issues, the efforts lack comprehensiveness and effective implementation. The result is a gap in defining and ensuring the existence of comprehensive systems for emergency medical care.
How does the absence of an emergency care law impact care, and consequently, patient outcomes?
We have witnessed the stark repercussions of the absence of a legal framework in two recent cases. In Lucknow, the son of a former member of Parliament faced the tragic outcome of being unable to secure a hospital bed after a referral, ultimately leading to his death. Similarly, in Delhi, filmmaker Piyush Pal lost his life while waiting for help, encountering delays in bystander care, and being transported to a hospital farther away than the nearest trauma centre. The transfer, reportedly conducted by the police, may have lacked crucial care, resulting in the loss of a young life.
The 201st Law Commission of India Report states that 50% of those killed in road crashes could have been saved had they received timely emergency medical care. It's important to note, however, that this report, released in 2006, is now outdated concerning the most recent data available.
The absence of a legislative system has not only hindered the assurance of trauma care but has also contributed to a concerning rise in death and disability across the country. Numerous documented cases from the recent past highlight how delayed trauma care, denial of care, or multiple referrals to different facilities have tragically resulted in loss of life.
In your study, did you estimate the time that it takes from an accident to the arrival of an ambulance reaching hospital and how it varies across locations?
Presently, the country lacks credible data on response times as these figures are self-reported by ambulance services without independent verification. Instances have been documented where recorded response times were as low as five or six minutes, while our documentation revealed actual response times of 40 minutes. This lack of independent oversight extends to quality of care, response times, handover time to hospitals, and similar metrics.
Contrastingly, our study could establish benchmarks based on practices in other countries. In three Australian states, the handover time for major incidents, defined from the scene to the hospital, is benchmarked at 60 minutes. This benchmark aligns with the advanced quality of care within ambulances in those states. In the state of Victoria, Australia, the benchmark time is an impressive 20 minutes for the scene to hospital journey. In Malaysia, the response time, from call to ambulance arrival, ranges between 15 to 30 minutes.
In India, there is currently no mandated response time or handover time for ambulances, leading to an absence of benchmarks. The International Human Rights Commission noted in 2004 that prehospital care, specifically the ambulance component in emergency cases, represents the weakest link in India's healthcare delivery, necessitating a thorough examination.
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