|Year : 2020 | Volume
| Issue : 3 | Page : 250-257
Gangasagar Mela 2019: Evaluation of health care in the mass gathering
Sumanta Chakraborty1, Basudeb Mitra2, Debasis Roy3
1 Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
2 Accounts Officer, Diamond Harbour Health District, Diamond Harbour, West Bengal, India
3 Chief Medical Officer of Health, Diamond Harbour Health District, Diamond Harbour, West Bengal, India
|Date of Submission||29-May-2019|
|Date of Decision||15-Aug-2019|
|Date of Acceptance||15-Oct-2019|
|Date of Web Publication||3-Jun-2020|
22/108, Raja Manindra Road, Kolkata - 700 037, West Bengal
Source of Support: None, Conflict of Interest: None
Context: One health concept relies on the principle of human health, animal health, and environmental health. Mass gatherings challenge all of them and warrant the transmission of infectious diseases, physical injuries, and an impact on local and global health systems and services. Thereby, a robust and coordinated management of various sectors is solicited to mitigate the challenges of health care in the pop-up townships of mass gathering. Aims: The aim of the study is to evaluate the curative, preventive, promotive, and medicolegal health services of the pilgrims. Settings and Design: A descriptive epidemiological study with cross-sectional design was conducted in the Gangasagar Mela 2019. Subjects and Methods: The observational epidemiological study was done through interaction with the concerned authorities: transect walk and survey of curative, preventive, and medicolegal health services using all enumeration techniques. Statistical Analysis Used: The data were analyzed using the principles of descriptive statistics. Results: Outpatient department attendance at five temporary hospitals was 6176 patients. Predominant complaints were respiratory ailments followed by gastrointestinal complaints. Inpatient department (IPD) including field-level high dependency unit and trauma care center admissions were 190 patients, of whom 25 were referred to higher facilities and 2 deaths occurred. Conclusions: The study provided an opportunity to generate an evidence base for generation of solutions and recommendations for the prevention and control of infectious diseases and accidents during the mass gatherings. This could provide information on the development of context-specific methods for the improvement and sustainment of optimum health and sanitary conditions for the visitors during Gangasagar Mela or any other mass gatherings across the globe.
Keywords: Gangasagar Mela, health care, mass gatherings, pop-up town, Sunderbans
|How to cite this article:|
Chakraborty S, Mitra B, Roy D. Gangasagar Mela 2019: Evaluation of health care in the mass gathering. Med J DY Patil Vidyapeeth 2020;13:250-7
| Introduction|| |
The World Health Organization defines a mass gathering as more than a specified number of persons at a specific location for a specific purpose for a defined period of time. The number of persons may be as few as 1000, although much of the available literature refers to the gatherings exceeding 25000 persons.
Despite the fact that these events are typically self-trigged (with people who are ill usually staying away), they generate a higher incidence of injury and illness than the general population statistics.
Mass gatherings of people at religious pilgrimages and sporting events are linked to numerous health hazards, including the transmission of infectious diseases, physical injuries, and an impact on local and global health systems and services. As with other forms of disaster, mass gathering-related disasters are the product of the management of different hazards, levels of exposure, and vulnerability of the population and environment and require comprehensive risk management that looks beyond single hazards and response.
The Gangasagar Mela is held annually on Sagar Island's southern tip, where the Ganges enters the Bay of Bengal forming an estuary. This confluence is also called Gangasagar, a site for Hindu pilgrimage across the Globe occurring every year in January on the eve of Makar Sankranti. Near the confluence is the Kapil Muni Temple. The Gangasagar pilgrimage and Mela is the second largest congregation of human beings after the triennial ritual bathing of Kumbha Mela. In 2019, 34 lakhs pilgrims took part in the holy dip ritual on the auspicious event of Makar Sankranti, a Hindu festival held at Sagar Islands, West Bengal, India.
For the purpose of Gangasagar Mela, the government creates “a pop-up megacity,” in the Sagar Island to shelter visitors on the dry flood plains for the duration of the Mela, after which everything is disassembled and the site returns to being rich agricultural land.
The sheer magnitude of the event poses a significant logistical and public health problem, and exploring its management and execution could provide crucial lessons and highlight the challenges faced in the management of mass gatherings from a public health perspective.
Incorporating an all-hazard, prevention-driven, evidence-based approach that is multisectorial and multidisciplinary is strongly advocated by the Sendai Framework for Disaster Risk Reduction 2015–2030.
A unified approach is warranted to better manage the public health needs and face the public health challenges during the mass gatherings. Thereby, it is imperative to conduct academic research on different mass-gathering events like the Gangasagar Mela. The ultimate aim is to create a multidisciplinary global consortium that can share data, engage in research, and develop guidelines for mass-gathering health.
The main objectives of the study were as follows:
- To evaluate preventive and health promotion services
- To assess the curative services
- To analyze the statutory and medicolegal services.
| Subjects and Methods|| |
It was a descriptive epidemiological study.
This was a cross-sectional design.
Sagar Island is situated in the Sunderbans, located in the Kakdwip subdivision of West Bengal [Figure 1]. It hosts the Gangasagar Mela each year during the month of January. There are five temporary hospitals being constructed during the Mela each year in the Sagar block as also adjoining blocks like Kakdwip and Namkhana like Sagar Mela Ground temporary hospital, Chemaguri temporary hospital, Kachuberia temporary hospital, Lot-8 temporary hospital, and Narayanpur temporary hospital.
The study duration was from 9th to 17th January 2019.
Study participants were pilgrims attending the study area.
Sample size and sampling technique
All enumeration techniques were used. No sampling was done.
Tools and techniques
- Interaction with the concerned authorities
- Transect walk
- Survey of curative, preventive, and medicolegal health services.
Interaction with health administrators like doctors and general administrators like public health engineering and fire service personnel was done to understand the overall scenario of the gathering. Information was obtained regarding the measures taken by them and the challenges they face in organizing the event.
Transect walk was done to observe the Mela ground in totality with focus on health facilities such as hospitals, first aid centers, NGO-run health facilities, and other facilities such as water and sewage facilities, food counters, fire stations, and scavenging facilities. This is done to validate the observations of the different administrators.
Data were obtained from curative, emergency, preventive, promotive, and medicolegal services in all five temporary hospitals in different community development blocks constructed to deliver health-care services to the pilgrims of Gangasagar.
The data were analyzed using the principles of descriptive statistics.
The study was conducted after obtaining the approval from all the concerned authorities and government officials who were involved in the Mela organization and management.
| Results|| |
The Gangasagar Mela 2019 started on January 9 and continued till January 17, for which the pop-up township for mass gatherings was created to deliver different facilities to the pilgrims, including health facilities. The Chief Medical Officer of Diamond Harbour Health District was the overall in-charge of the health administration of Gangasagar Mela 2019. The health department had health officers, nurses, pharmacists, and laboratory technicians deployed at five temporary hospitals. Auxiliary nursing midwives (ANMs) and pharmacists were deployed at first-aid booths at the Mela ground, transit points, and buffer zones to provide curative, preventive, and promotive health services to the lakhs of Pilgrims visiting the Gangasagar Mela. Trained volunteers were involved by the Diamond Harbour Health District Team to provide primary health care to the pilgrims [Table 1].
Curative health interventions
Outpatient department (OPD) attendance at five temporary hospitals was 6176 patients. Predominant complaints were acute respiratory tract infections 917 cases including 3 cases of pneumonia and 408 cases diarrhea including 23 cases of bacillary dysentery. Preexisting noncommunicable diseases were found in 1582 OPD attendees, on which diabetes was present in 94 cases, chronic obstructive pulmonary disease (COPD) in 86 cases, and hypertension in 1468 pilgrims.
Six chicken pox cases were detected among government employees of various departments. There were three cases in Mela ground, one case in Chemaguri, and two cases in Lot 8. No clustering of cases was detected. The aforesaid cases were treated and released from their duties by their respective point-in-charge to prevent chick pox outbreak in the camps for the employees.
IPD admissions included 190 patients, of whom 25 were referred to higher facilities, 2 pilgrims expired, and 161 patients were managed adequately after admission at the temporary hospitals. 7 burns, 8 fractures, 4 acute myocardial infarction, 86 acute exacerbation of COPD, 12 acute gastroenteritis with severe dehydration, 5 delivery cases, and 68 fever cases were admitted in the inpatient services during the Mela.
Critical care unit
Four critically ill patients with cardiovascular problems were treated at the temporarily built critical care unit (CCU). Mechanical ventilation was required in two patients. The use of recombinant tissue plasminogen activator in two patients and streptolysin in one patient was noted and was used for saving the lives. Adenosine was used to correct cardiac tachyarrhythmia in one patient. four CCU-trained doctors and 16 CCU-trained nurses under the supervision of an experienced cardiologist were designated for the field CCU.
RRT for trauma care
In 2019, trauma care team with orthopedic surgeons, general surgeons, and anesthetists, deployed at SagarMela Ground Temporary Hospital. There were 1 road traffic accidents involving 11 persons. Nobody succumbed to death due to injury. Plaster of paris cast (POP) casting was done in eight patients. 151 injuries were managed locally. Seven serious burn injuries were treated with medical treatment, while dressing and care were provided at the temporary hospital by two orthopedic specialists and four general surgeons.
Obstetric emergency team at Sagar Rural Hospital
A comprehensive emergency obstetric care center was established at Sagar Rural Hospital with the availability of obstetricians, anesthesiologists, and blood storage facilities round the clock. This was done due to the congestion of transhipment mothers of Sagar Island and also to care of the pregnant pilgrims. There were total four cesarean deliveries during the Mela. Furthermore, there was one delivery in the boat, while referral which was managed by the mobile medical team of Narayanpur Temporary Hospital.
A 60-mA portable X-ray machine was set up at the SagarMela Ground Temporary Hospital for the pilgrims with no service charges for them. A total of 82 patients underwent free radiographs.
Electrocardiogram (ECG) facilities were provided at all the temporary hospitals. A total of 160 ECGs were conducted, including 12 in Chemaguri, 17 in Narayanpur, 11 in Lot 8, and 120 at SagarMela Ground Temporary Hospital.
Blood testing kits for blood sugar, hemoglobin, malaria, HIV, and Trop T were supplied. Many blood tests were conducted including four Trop T tests. There were provisions for urine testing kits, stool transport media, and viral transport media along with personal protective equipment at the temporary hospitals.
Free drugs and consumables
Adequate catalog and noncatalog drugs were made available by DRS of Diamond Harbour Health District of Government of West Bengal. High-end CCU drugs were also available in the Mela ground temporary hospital. Oseltamivir was available in preparedness of any influenza outbreak in the mass gatherings.
Along with the drugs, all consumables including the provision of free customized diets such as diabetic diet, and renal diet were available in the temporary hospitals.
At the field level, 31 first-aid booths manned by ANMs and pharmacists were deployed primarily at areas catering the transit points and Mela ground. Measurement of blood pressure, blood sugar, and symptomatic management of common ailments was offered in the first aid centers with a provision for referral of complicated cases to the temporary hospitals, for which free-of-cost ambulance services were also provided. A total of 15,848 pilgrims attended the first aid booths, of which 52 were referred to the temporary hospitals for further treatment. Surveillance data revealed 1161 acute gastroenteritis cases, 2250 cases of acute respiratory tract infections among communicable diseases. Among the noncommunicable diseases, 48 cases with preexisting cardiorespiratory ailments and 190 cases of various injuries were managed locally at the booths.
Mobile health teams
Mobile medical units were deployed on large barges for 24 × 7 duties as per the requirement of the general administration of Gangasagar Mela.
Flying medical squads were deployed at transit points in Kachuberia, Lot 8, and Narayanpur Temporary Hospitals. National disaster response force (NDRF) help was taken to mobilize the flying medical teams using inflatable motorboats. A normal delivery was done in the boat itself by the mobile medical team from Narayanpur.
A mobile unit was deployed at the helipad of Gangasagar Mela ground. Another mobile health team was deployed on the holy dip day at the beach to treat any possible hypothermia patient.
A mobile unit consisted of a medical officer, one pharmacist, one staff nurse, and one general duty assistant (GDA).
Nongovernmental organization networks
A synergy of public-private partnership was observed for improving patient care in the mass gathering of Gangasagar Mela 2019. Forty-one voluntary organizations were provided free drugs for treatment of the pilgrims. The NGO network of medical camps and first aid booths attended 69,729 patients at five sector points over 6 days during the Gangasagar Mela 2019.
At the NGO-run medical camps, the patients comprised 5292 acute gastroenteritis, 22,885 acute respiratory tract infections, and 4361 injury patients. Although the utilization certificates of medicines were pending from the NGOs till the official closing of the Mela, 50 NGO-run ambulances were deployed at the transit routes, buffer zones, and Mela ground. Transhipment of patients and health officials were through two NGO-run launches with minimal charges for the fuel costs.
Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) services
A team of 6 AYUSH doctors was available at the Sagar Mela Ground Temporary Hospital AYUSH dispensary with provisions of free homeopathy medicines.
Preventive and health promotion interventions
Information, education and communication programs
A theme campaign of free health services of the Government of West Bengal “Swasthya Sarbadhikar o Somanadhikar” was widely promoted through visual publicity media starting from the transit roads to the Gangasagar Mela ground.
WBSAP and CS had approved an information, education and communication (IEC) program on safe sexual behavior, safe blood transfusion, and promotion of voluntary testing of HIV through street plays and folk songs during the Mela. There were two troupes which performed about 18 such campaigns form January 10, 2019 to January 16, 2019. About 3000 people attended the programs. Special emphasis was given targeting the youth camps of various voluntary organizations around the Mela premises.
The Diamond Harbour Health District administration conducted a “Save the girl child” campaign with a stage play organized by BMOH Sagar rural hospital. The staffs and local performers performed near the temporary hospital premises of the Mela ground and were attended by over 200 youths.
IEC programs were organized on various national programs such as Revised National Tuberculosis Control Program, National Program for Control of Blindness and Visual Impairment, National Tobacco Control Program, National Program for Control of Diabetes, Cardiovascular Diseases and Stroke, National Iodine Deficiency Disorders Control Program, Reproductive, Maternal, Neonatal and Child Health + Adolescent Program, National Leprosy Eradication Program, National AIDS Control Program, Swasthya Sathi Program by means of flex, banner, and posters across all transit points, buffer zones, and Mela ground with good visuality all around the Mela premises in Bengali as well as Hindi for visual campaigning for health.
Folk songs and magic programs were organized and attended by about 1800 pilgrims. The theme of these programs was health promotion.
Cleanliness and sanitation campaign
Public toilet facilities were present throughout the Mela premises and transit points. Those were constructed and maintained by Public Health Engineering Department (PHED) of the Government of West Bengal. The Diamond Harbour Health District had deployed 75 personnel mainly health assistants and health supervisors at five sectors to monitor the cleanliness campaign. The cleaners or Karmabandhus worked under the Supervision of Health Supervisors and Health Assistants. Karmabandhus were provided from Public Health Engineering Department of Government of West Bengal for the Mela ground and Panchayat and rural development bodies at the four transit points as follows:
- Gangasagar Mela Ground – 200
- Chemaguri point – 30
- Kachuberia Point – 40
- Lot 8 Point – 70
- Namkhana Point – 40.
Fifty wheelbarrows were utilized for the solid waste management.
Monitoring was conducted in two shifts as per se ctor mapping and prior microplanning. 1271 lanes, 1806 by-lanes, and 7639 pilgrim sheds were visited from January 10, 2019 to January 16, 2019, i.e. over a period of 7 days. 56,915 latrines, 7750 urinals, and 5029 garbage dump were visited and monitored for cleanliness.
Food safety promotion
Four food safety officers deputed by the Commissioner of Food Safety under the guidance of Deputy CMOH II of South 24 Parganas were entrusted upon the food safety promotion work. Nonpermitted colors used were seized from the Mela ground and other places by the team from about 200 shops. Expired packed food items worth Rs. 1 lakh approximately were seized and destroyed. The shopkeepers were trained about use of permitted food colors, proper covering of food items, and serving the food hot and fresh. Hand hygiene was advocated about 1000 pilgrims.
Prohibition of tobacco products
Dy. CMOH II, South 24 Parganas, as per the COTPA statute, with his team seized illegally displayed tobacco products worth Rs. 50,000 approximately. The shopkeepers were trained about nondisplay of tobacco items. Ill effects of tobacco were advocated to about 600 pilgrims by IEC posters of the National Tobacco Control Program.
Safe water promotion
Safe drinking water was provided to the pilgrims free of cost from the PHED of Government of West Bengal in sealed pouches. It was made available in all nook and corners of the Mela premises. The three-member Central Combined Laboratory Team headed by a clinical microbiologist deployed by the Department, tested 200 water samples for free chlorine test. Fourteen samples were found unsatisfactory. A total of 91 samples including the 14 unsatisfactorily chlorinated samples were incubated for bacteriological analysis. Eight-seven samples were found satisfactory and 4 samples turned out to be unsatisfactory. PHED was informed both about unsatisfactorily chlorinated samples as well as about bacteriological analysis. Resampling was done on subsequent days to test adequate chlorination.
Statutory and medicolegal services
- Postmortem services were provided at a temporary morgue in Sagar Rural Hospital
- There were six deaths in Gangasagar Mela 2019 [Figure 2]. Postmortem was done at the morgue of Kakdwip subdivisional hospital. Four dead bodies were handed over to the family members after medical certification of cause of death
- Under Registration of Births & Deaths Act (RBD Act), online death registrations were done for all death cases
- General administration was informed for smooth dispersal of social assistance amount to be disbursed to family of the deceased by the Government of West Bengal
- Two Launches of an NGO “SHIS” were used for the supply of medicines, equipment, cots, mattress, along with movement of staffs and officers, as well as, transportation of sick patients from the island to main land hospitals
- Basic fire protection was arranged in all temporary hospitals
- Information communication report returns were shared through WhatsApp group for Gangasagar Mela 2019. Immediate sharing of pictures of missing person and their subsequent identification were facilitated through this network.
|Figure 2: Bar diagram showing the comparative analysis of beneficiaries and deaths in Gangasagar Mela between 2018 and 2019|
Click here to view
| Discussion|| |
The study reveals that the health administration keeping in liaison with the general administration of the Government of West Bengal and NGOs was successful in proper planning, management, coordination, supervision and monitoring of events and timely interventions as and when needed in Gangasagar Mela 2019. The results were evident from the reduced number of deaths of pilgrims this year [Figure 2]. Our study findings were consistent with the studies done on Kumbh Mela by Cariappa et al. in 2015 and Mishra in 2004., They termed the Mela as successful owing to the reports of no outbreaks during the Mela, which stands true for Gangasagar Mela 2019, as there were no major outbreaks of any disease. A global approach for health risk assessment in mass events like the one existing for Hajj pilgrims (HAHU Research Group) is lacking in Kumbh Mela and Gangasagar Mela.
The pop-up township of Mela was not dirty. There were cleaned bins for solid waste disposal everywhere, and the low number of mosquitoes and flies made it safer to live. Around 75 health supervisors worked round the clock to monitor the cleanliness of the area. Monitoring was conducted in two shifts as per se ctor mapping and prior microplanning. 1271 lanes, 1806 by-lanes, and 7639 pilgrim sheds were visited from January 10, 2019 to January 16, 2019, i.e. over a period of 7 days. A total of 56,915 latrines, 7750 urinals, and 5029 garbage dumps were visited and monitored for cleanliness.
There was provision of potable drinking water with adequate chlorination, cross verified by the microbiological culture report of a medical microbiologist. Portable toilets for both genders were present in and around every nook and corners of the town with adequate cleanliness. Expired food confiscation was satisfactory, but covering of food items and hand hygiene of pilgrims were very unsatisfactory. Tobacco products were sold and used randomly throughout the township. IEC materials were present in all prominent locations of the Mela premises.
Field-level high dependency unit under the supervision of a consultant cardiologist and trauma care facility under an orthopedic specialist with provisions for air-lifting was a new initiative in the Island town amidst the Sunderbans. OPD attendance at five temporary hospitals was 6176 patients. The result was consistent with a study on infectious diseases in mass gatherings of Hajj pilgrims., Predominant complaints were Respiratory ailments followed by gastrointestinal complaints. Respiratory ailments had an upsurge between 12th and 15th January when the crowd was at its peak and was promptly managed locally as shown in [Figure 3]. There were considerable outliers in the reporting of AGE and acute respiratory infection cases as shown in [Figure 4]; on further investigation, it was found that it occurred due to overreporting form the NGO run clinics and the first aid center where only symptomatic treatments were provided rather than comprehensive health checkups by physicians in the OPDs. Respiratory illnesses were also found to be the most common ailments in studies on mass gatherings such as Kumbh Mela  and Hajj. Acute diarrheal diseases ranked second most common in our study but fourth in Kumbh Mela and third in Hajj, while injuries ranked third in our study as also in Kumbh Mela, but in Hajj, it was the most common noninfectious cause of mortality and morbidities., IPD admissions were 190 patients, of whom 25 were referred to higher facilities and 2 deaths were there in the facility as shown in [Figure 2]. All the medical and health-care facilities were provided free of costs.
|Figure 4: Box and Whiskers plot showing pattern of diseases reported from the hospital as well as first aid centers and nongovernmental organization-run clinics|
Click here to view
The results were evident from the fact there was reduction in death cases among pilgrims, i.e., only 6 deaths (there were 16 deaths in 2018) among 34 lakhs pilgrims. In the year 2018, there were 16 deaths. It is worthwhile to mention that Gangasagar Mela located in the remote island of the southernmost tips of West Bengal amidst the mighty Sunderbans and Bay of Bengal was considered one of the most dangerous places of worship by pilgrims. However, coordinated and efficient management of cases with provision of field-level CCU and rapid response team (RRT) in one of the remotest places of India made people return home safe and sound after their spiritual enlightenment.
| Conclusions|| |
The “pop-up city” that houses more than 3 million people in the middle of an island bounded by the river Ganges and the Bay of Bengal is significant not only for pilgrims across the globe but also for research on mass gatherings. Although there was a lack of data maintenance in first aids centers and NGO run centers, they helped in providing primary care services for the masses in their own capabilities with support and supervision form the government health department. Training of health-care providers on mass gathering medicines and proper data recordings and maintenance are two important, suggestions needed to be followed in the coming years. Studying the intricacies and complexities of the mammoth Gangasagar Mela 2019 presents a unique opportunity to generate an evidence base for the generation of solutions and recommendations for the prevention and control of infectious diseases and accidents during the mass gatherings. This could provide information on the development of context-specific methods for the improvement and sustainment of optimum health and sanitary conditions for the visitors during the Gangasagar Mela or any other mass gatherings across the globe. Further interventional research is needed on the Gangasagar Mela to bring into focus new innovations and practices that may culminate further improvement in health-care delivery in mass-gathering events.
Heartily indebted to different departments of the Government of West Bengal, various NGOs, and the pilgrims of Gangasagar Mela for providing information required for the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]