Burning Beds

No lo digo para criticar al personal;

I say this not to criticize the staff;

lo digo porque es el resultado lógico de un sistema que prioriza los ingresos sobre la infraestructura de seguridad.

I say it because it is the logical result of a system that prioritizes revenue over safety infrastructure.

I want to stay on the private hospital boom for a minute, because the growth numbers are genuinely staggering.

India's private healthcare sector has roughly tripled in size since the early 2000s.

Y hay que entender por qué.

And one must understand why.

El gasto público en salud en India es históricamente bajo, alrededor del 1,5 o 2 por ciento del PIB durante décadas, muy por debajo de la media mundial.

Public health spending in India has historically been low, around 1.5 or 2 percent of GDP for decades, well below the global average.

Cuando el Estado no cubre la demanda, la gente acude al sector privado aunque eso signifique endeudarse, vender tierras, pedir dinero prestado a la familia.

When the state does not meet demand, people turn to the private sector even if that means going into debt, selling land, borrowing money from family.

En India, los gastos médicos son una de las principales causas de pobreza extrema.

In India, medical expenses are one of the main causes of extreme poverty.

So the people dying in this fire were already in a precarious position.

They were in a private hospital not because they chose comfort but because the public option wasn't there.

Muy probablemente.

Very likely.

Y eso añade una capa de injusticia que va más allá del incendio en sí.

And that adds a layer of injustice that goes beyond the fire itself.

Estas personas ya habían sobrevivido al sistema público insuficiente, habían encontrado un hospital privado, habían conseguido llegar a la UCI, y entonces mueren por algo que no tiene nada que ver con su enfermedad.

These people had already survived the inadequate public system, had found a private hospital, had managed to reach the ICU, and then they die from something completely unrelated to their illness.

Es una cadena de fallos institucionales, no un accidente aislado.

It is a chain of institutional failures, not an isolated accident.

I covered a hospital collapse in Bangladesh back in 2013, different context obviously, but the same underlying dynamic.

Building that shouldn't have been there, inspectors who'd been paid off, and the people inside had no idea.

Es que la corrupción en los procesos de inspección es el hilo conductor de todos estos casos.

Corruption in inspection processes is the common thread running through all these cases.

No es solo negligencia.

It is not just negligence.

Es un sistema en el que los inspectores saben perfectamente que el hospital no cumple los requisitos, y miran hacia otro lado a cambio de algo.

It is a system in which inspectors know perfectly well that the hospital does not meet requirements, and they look the other way in exchange for something.

Y mientras tanto, los pacientes asumen que si el hospital está abierto, es porque es seguro.

And meanwhile, patients assume that if the hospital is open, it must be safe.

Una confianza que no tienen ningún motivo racional para depositar ahí.

A trust they have no rational reason to place there.

There was a national fire safety audit of hospitals ordered after the AMRI fire.

What actually came of it?

Lo que suele ocurrir en estos casos: hubo informes, hubo comisiones, hubo declaraciones de intenciones.

What usually happens in these cases: there were reports, there were committees, there were declarations of intent.

Algunos estados respondieron con más seriedad que otros.

Some states responded more seriously than others.

Pero Bihar, que es exactamente el tipo de estado que más necesitaba una reforma estructural, siguió siendo uno de los menos preparados.

But Bihar, which is exactly the type of state most in need of structural reform, remained one of the least prepared.

La brecha entre la ley nacional y la aplicación local en un estado con las instituciones tan debilitadas como Bihar es enorme.

The gap between national law and local enforcement in a state with institutions as weakened as Bihar is enormous.

And the political dimension of that is uncomfortable, because Bihar has been one of the most politically significant states in Indian national elections for decades.

Exacto, tiene una importancia electoral enorme.

Exactly, it has enormous electoral importance.

Y sin embargo, esa relevancia política no se ha traducido en inversión en infraestructura sanitaria proporcional a su peso político.

And yet that political relevance has not translated into healthcare infrastructure investment proportional to its political weight.

Es un estado que genera votos pero no genera suficiente presión para que esos votos se traduzcan en hospitales seguros.

It is a state that generates votes but does not generate enough pressure for those votes to translate into safe hospitals.

En parte porque los votantes más pobres, que son los más afectados, tienen menos capacidad de exigir rendición de cuentas.

In part because the poorest voters, who are most affected, have less capacity to demand accountability.

That's the bind, isn't it.

The people most exposed to these risks are the same people with the least institutional leverage to change them.

Y hay un factor adicional que no se puede ignorar: la impunidad casi total que suelen disfrutar los propietarios de estos hospitales.

And there is an additional factor that cannot be ignored: the near-total impunity that owners of these hospitals typically enjoy.

Después del incendio del AMRI, los dueños fueron arrestados, sí, pero las condenas efectivas son rarísimas.

After the AMRI fire, the owners were arrested, yes, but actual convictions are extremely rare.

En general, los procesos judiciales se alargan años, las multas son simbólicas, y al final el coste de no cumplir las normas es mucho más bajo que el coste de cumplirlas.

Generally, legal proceedings drag on for years, fines are symbolic, and ultimately the cost of not complying with regulations is far lower than the cost of complying.

Esa es la ecuación que hay que cambiar.

That is the equation that needs to change.

I want to bring in the comparative angle, because this isn't exclusively an Indian problem.

South Korea had a catastrophic hospital fire in 2018.

South Korea, which we think of as a country with strong institutions.

El incendio del hospital Sejong en Miryang, sí, murieron 37 personas.

The Sejong Hospital fire in Miryang, yes, 37 people died.

Pero fíjate en la diferencia de respuesta institucional: hubo una revisión sistemática de todos los hospitales del país, se endurecieron las sanciones penales para los propietarios que incumplieran las normas de seguridad, y se publicaron los resultados.

But notice the difference in institutional response: there was a systematic review of every hospital in the country, criminal penalties for owners who violated safety standards were toughened, and the results were published.

No te digo que fuera perfecto, pero la respuesta del Estado fue cualitativamente distinta.

I'm not saying it was perfect, but the state's response was qualitatively different.

Hay voluntad política y hay capacidad institucional para actuar.

There is political will and there is institutional capacity to act.

Which points to the real gap.

It's not that India lacks the knowledge of what good hospital fire safety looks like.

The knowledge exists.

The regulatory framework, at least on paper, exists.

The question is whether there's genuine political will to enforce it in places like Bihar.

Y la respuesta honesta, mirando el historial de los últimos veinte años, es que esa voluntad política ha sido profundamente insuficiente.

And the honest answer, looking at the track record of the last twenty years, is that political will has been profoundly insufficient.

Lo que suele ocurrir es que hay un incendio, hay titulares durante tres o cuatro días, hay declaraciones indignadas de los políticos de turno, y luego la atención se desplaza a otra cosa.

What usually happens is that there is a fire, there are headlines for three or four days, there are indignant statements from whatever politicians are in office, and then attention shifts to something else.

Hasta el próximo incendio.

Until the next fire.

Y hay un próximo incendio, siempre.

And there is a next fire, always.

There's a phrase I keep thinking of from public health policy: 'amenable mortality.' Deaths that shouldn't happen given what we know.

This is that.

Es una expresión muy precisa para describir lo que ocurre.

That is a very precise expression to describe what happens.

Estas muertes no son inevitables.

These deaths are not inevitable.

Son el resultado de decisiones tomadas o no tomadas por actores con nombres y apellidos: propietarios de hospitales, funcionarios de inspección, gobernadores de estado, ministros de salud.

They are the result of decisions made or not made by actors with names and faces: hospital owners, inspection officials, state governors, health ministers.

La tragedia tiene autores, aunque rara vez se les exige que respondan por ello.

The tragedy has authors, even if they are rarely held to account for it.

What would meaningful reform actually look like?

Because I don't want to end on pure despair here.

Mira, hay modelos que funcionan.

Look, there are models that work.

Primero, registros públicos de inspecciones hospitalarias, de acceso abierto, para que los pacientes puedan saber si el hospital donde van a ingresar ha pasado los controles de seguridad.

First, public registries of hospital inspections, openly accessible, so patients can know whether the hospital they are being admitted to has passed safety checks.

Segundo, sanciones penales reales y rápidas para los propietarios que incumplan, no multas simbólicas que tardan diez años en resolverse.

Second, real and swift criminal penalties for owners who fail to comply, not symbolic fines that take ten years to resolve.

Tercero, inversión seria en el sector público para que la gente no dependa de clínicas privadas que operan al margen de cualquier control.

Third, serious investment in the public sector so that people are not dependent on private clinics operating beyond any oversight.

The transparency piece is interesting to me.

There was a push in several Indian states a few years ago to publish hospital ratings publicly.

Did that go anywhere?

De forma muy parcial.

In a very partial way.

Algunos estados con mejor gobernanza, como Kerala o Tamil Nadu, han avanzado más en ese sentido.

Some states with better governance, like Kerala or Tamil Nadu, have made more progress in that direction.

Pero Bihar es precisamente el tipo de estado donde esas iniciativas encuentran más resistencia, porque los intereses creados son más fuertes y las instituciones reguladoras más débiles.

But Bihar is precisely the type of state where those initiatives meet the most resistance, because vested interests are stronger and regulatory institutions are weaker.

No es casualidad que los estados con mejor infraestructura sanitaria en India sean también los que tienen más tradición de exigencia ciudadana y administraciones menos corruptas.

It is no coincidence that the states with the best healthcare infrastructure in India are also those with a stronger tradition of civic demand and less corrupt administrations.

Kerala is almost its own story.

The healthcare outcomes there are genuinely remarkable relative to income levels.

The comparison with Bihar within the same country is stark.

Brutalmente stark, sí.

Brutally stark, yes.

Es uno de los grandes debates en los estudios de desarrollo: por qué dentro de un mismo país las diferencias en resultados sanitarios pueden ser tan enormes.

It is one of the great debates in development studies: why within the same country the differences in health outcomes can be so enormous.

Y la respuesta casi siempre remite a la historia política de cada estado, a si hubo reformas agrarias, a si los sindicatos eran fuertes, a si la sociedad civil tenía capacidad de presión.

And the answer almost always points back to the political history of each state, to whether there were agrarian reforms, to whether unions were strong, to whether civil society had leverage.

Son décadas de historia condensadas en una estadística de mortalidad.

Decades of history condensed into a mortality statistic.

Which is why these four deaths in Muzaffarpur are not just a tragedy.

They're a diagnostic.

They tell you something specific and precise about the state of a system.

Bien dicho.

Well said.

Y lo más triste es que mañana habrá otro titular que desplace a este, y la semana que viene nadie recordará los nombres de esas cuatro personas.

And the saddest thing is that tomorrow there will be another headline that displaces this one, and next week no one will remember the names of those four people.

A menos que alguien, ya sea un periodista, un activista, un político con algo de valentía, decida que esta vez las cosas van a ser distintas.

Unless someone, whether a journalist, an activist, a politician with some courage, decides that this time things will be different.

Aunque la historia no invita al optimismo.

Although history does not invite optimism.

One thing before we go, actually.

You used a phrase earlier that I've been wanting to ask about.

You said something like 'a menos que alguien decida.' That construction.

'A menos que' es una conjunción condicional negativa, y siempre va seguida de subjuntivo.

'A menos que' is a negative conditional conjunction, and it is always followed by the subjunctive.

Siempre, sin excepción.

Always, without exception.

Puedo decir 'las cosas van a cambiar a menos que alguien lo impida', o 'no saldré a menos que llueva'.

I can say 'things are going to change unless someone stops it', or 'I won't go out unless it rains'.

La condición que introduce 'a menos que' es la única que podría cambiar el resultado, y por eso el verbo que le sigue necesita el modo subjuntivo, porque expresa una posibilidad, no una certeza.

The condition introduced by 'a menos que' is the only one that could alter the outcome, and that is why the verb that follows it needs the subjunctive mood, because it expresses a possibility, not a certainty.

So it's like 'unless' in English, which also sort of implies a counterfactual.

The thing that would have to happen for the normal outcome to be interrupted.

Esa analogía funciona bastante bien.

That analogy works quite well.

La diferencia es que en inglés puedes ser más descuidado con el modo verbal después de 'unless' y nadie te lo reprocha demasiado.

The difference is that in English you can be more careless with the verb mood after 'unless' and nobody really holds it against you.

En español, usar un indicativo después de 'a menos que' es un error que suena mal incluso en una conversación informal.

In Spanish, using an indicative after 'a menos que' is a mistake that sounds wrong even in informal conversation.

El subjuntivo no es opcional ahí.

The subjunctive is not optional there.

Unlike my Spanish in general, where apparently everything is optional and I'm just hoping for the best.

Thanks, Octavio.

And thanks to everyone listening.

De nada.

You're welcome.

Y si alguien en Bihar está escuchando esto, espero que el hospital más cercano tenga, como mínimo, extintores que funcionen.

And if anyone in Bihar is listening to this, I hope the nearest hospital has, at the very minimum, fire extinguishers that actually work.