Encephalitis in Bihar: Rising deaths not only reveal poor infrastructure, but also Nitish Kumar govt's failure to tackle seasonal crisis

The death of over 150 children in Bihar due to Acute Encephalitis Syndrome (AES) has not only laid bare the poor health infrastructure in the state, but also showed how inept the state's leadership — political as well as administrative — are in tackling a crisis.

In Bihar, doctors were scrambling to find reasons and solutions and political parties were aiming potshots at each other even as the number of children succumbing to AES kept rising. Since 1 June, 2019, over 500 children have been admitted to the two hospitals in Muzaffarpur — Sri Krishna Medical College Hospital (SKMCH) and Kejriwal Hopsital — of which 152 have died (111 children died at SKMCH alone).

 Encephalitis in Bihar: Rising deaths not only reveal poor infrastructure, but also Nitish Kumar govts failure to tackle seasonal crisis

Children suffering from Acute Encephalitis Syndrome (AES) being treated at a hospital in Muzaffarpur. PTI

This was despite the fact that AES outbreak is not uncommon in Bihar. Since 1995, when the first outbreak of encephalitis was reported in Muzaffarpur, cases have been reported almost every year between April and July since 1995.

According to the National Vector-Borne Diseases Control Programme (NVBDCP), in 2018, 33 people died to the brain fever, which usually occurs during the monsoon and leads to symptoms like fever, vomiting and convulsions, and affects children between ages of six months and 15 years.

In the year 2018, of the 1,073 encephalitis patients admitted to the BRD Medical College in Uttar Pradesh's Gorakhpur district, over a hundred were from Bihar. A study of 2018 AES cases and deaths show that though Bihar has seen a decrease in the number of AES cases reported and deaths from the peak of 1,358 reported cases and 355 deaths in 2014 to 124 cases and 33 deatsh in 2018 (provisional figures), when compared to other states Assam, Odisha, Uttar Pradesh, West Bengal, Tamil Nadu and Jharkhand, which recorded much higher AES cases in 2018, the ratio of deaths was the highest at 26 percent in Bihar.

 States Cases (2018) Deaths (2018) Percentage of deaths (2018)
Bihar 124 33 26.6
Assam 1492 183 12.27
Odisha 1720 10 0.58
Uttar Pradesh 3080 230 7.47
West Bengal 1762 146 8.29
Tamil Nadu 1287 5 0.39
Jharkhand 544 0 0
All India 11388 638 5.6

In the neighbouring Jharkhand, which reported 544 cases of AES in 2018, no child died.

This itself should have alarmed the Bihar administration. Yet, it was caught off-guard as AES cases continued to rise. Though the mounting toll has trained the focus on Muzaffarpur, cases have been reported through the year from Siwan, Gopalganj, East Champaran, Barauni and Gaya districts.

Compare Bihar's response to AES with Kerala's approach to contain the Nipah virus outbreak last year. In Kerala, government doctors recognised that they were dealing the Nipah virus and promptly began the treatment protocols. Every person a patient had come in contact was monitored for symptoms. All those suspected of being infected with the Nipah virus were moved to purpose-built isolation wards at Government Medical College (GMC), Kozhikode, where all medical personnel were equipped with safety equipment, The Wire had reported.

On the contrary, Bihar's response to the crisis tells the tale of a state that responds when disaster strikes but does not learn lessons from its history. Every time the encephalitis cases see a spike, the government is seen grappling in the absence of a comprehensive action plan and lack of readiness of hospitals. No lasting solutions have been sought from the World Health Organisation (WHO) or medical institutions of repute in India.

Uncertainity of cause

While a majority of deaths until 2005 were caused by Japanese Encephalitis, children have been succumbing to other forms of viral encephalitis in the past decade, according to BBC.

Some practitioners pin the cause of deaths among children suffering from AES on the lychee fruit, which in its unripe form, contains a toxin that inhibits the body's ability to produce glucose. This toxin can speed up blood sugar loss among young children with AES, leading to hypoglycemia. It is no coincidence that Muzaffarpur is the country's largest litchi cultivation region and a large number of those inflicted were children of orchard workers, according to News18.

Other practitioners say encephalitis in children is directly related to malnutrition. In Bihar and Uttar Pradesh, most patients hail from poor rural families. Many of them are children of labourers, including landless labourers, and some of them have left their villages and migrated to cities to earn a living. Malnutrition among children is more prevalent in districts affected by AES in these two states. The state governments, therefore, need to take urgent steps to tackle malnutrition.

Another set of practitioners blame the heat and humidity for the outbreak. SKMCH Medical Superintendent Sunil Kumar Shahi told PTI that with the onset of the monsoon, the number of AES cases will likely come down. "Like every year, the severity of the outbreak is diminishing with the onset of rains. This can be gauged from the fact that no deaths were reported on Monday and only five fresh cases were registered during the day. Till just a few days ago, we were receiving AES patients in droves," he said on Tuesday.

Where the problems lie

AES (and JE) continue to pose problems due to the scarcity of doctors, slow progress in drinking water projects in encephalitis-affected areas, lack of awareness campaigns regarding the viral and its link to malnutrition and difficulties in the identification of the causes of the diseases.

In 2016, the Bihar government released an advisory to curb the prevalence of AES. It involved having glucometers at primary health centres, door-to-door awareness campaigns in villages and advising locals to not eat unripe lychees. But none of these guidelines have been followed on the ground.

The lack of functioning public health centres is a recurring complaint, forcing those affected to travel for miles for treatment. In fact, of the 103 PHCs in the district, 98 could not even meet the minimum criteria for evaluation under the health ministry’s health management information system, The Times Of India reported. And of the remaining five, every single one got a rating of zero.

Amid a glaring case of administrative negligence and crumbling health infrastructure in the state, the patients this year were seen undergoing treatment on shared beds, grappling with inadequate drinking water and electricity failure causing the biggest hospital in the district to face heavy patient loads. The malnutrition among children pointing to the failure of Integrated Child Development Services (ICDS) and other health schemes.

Political name-calling continues as toll mounts

The state government’s lackadaisical approach, including Chief Minister Nitish Kumar’s visit to Muzaffarpur over a fortnight after the cases began to be reported, invited widespread criticism. It was then that he also announced that the 610-bed government hospital at Muzaffarpur would be converted into 2,500-bed hospital and construct a dharamshala for families of the AES patients. Earlier this week, Bihar health minister Mangal Pandey shocked reporters at a press conference held to talk about the tragedy by asking about India vs Pakistan cricket match scores.

In 2014, during the same AES outbreak, Harsh Vardhan had promised to open a 100-bed capacity hospital, but nothing has happened in this direction even after five years. It was only on 24 June, 2019, when the toll crossed 100, the Union minister constituted a high-level multi-disciplinary team to be sent to Bihar for undertaking necessary groundwork to set up a state-of-the-art research centre to tackle the disease. SKMCH still does not have a post graduate study centre for the paediatrics department.

The outbreak is proving to be a test of the NDA alliance in Bihar, causing the BJP and JD(U) to turn their backs to each other, amid the gradual souring of ties after Nitish refused to join Modi 2.0 cabinet over a disagreement over the seat-sharing deal.

In fact, when Vardhan visited SKMCH no JD(U) joined the Union health minister. The state's health minister Pandey was on foreign tour while the toll mounted.

Former union health minister and senior BJP leader CP Thakur accused the Nitish Kumar administration of reacting slowly to the epidemic, hinting at the saffron party distancing itself from a party under fire.

"Had they responded swiftly when the news of AES was first reported, many lives would have been saved. The government is responsible for this tragedy," he said.

Rashtriya Janata Dal (RJD) too has attacked the Bihar government for its alleged failure in the face of the outbreak. Former chief minister Rabri Devi, senior RJD leader Raghuvansh Prasad Singh, Shivanand Tiwari and Tej Pratap Yadav have scathingly attacked both the state and central governments, with Raghuvansh demanding Kumar’s resignation on moral grounds.

Rashtriya Lok Samta Party (RLSP) leader Upendra Kushwaha also sought Kumar’s resignation.

"The health services have been left to God's mercy. A mere assurance (to improve things) will not serve the purpose. Either you act or resign from the post of the Chief Minister, failing which the RLSP would hit the roads to expose him (Nitish) for his failures," he said.

Kushwaha said that against the sanctioned posts of 7,249 regular doctors in the state, only 3,146 doctors are currently working in government hospitals and 533 contractual doctors are working against 2,314 contractual posts in the state.

BJP MP from Muzaffarpur Ajay Nishad linked the encephalitis-related deaths in his constituency with the '4Gs' theory of gaaon (village), garmi (heat), garibi (poverty) and gandagi (poor hygiene). However, government think tank NITI Aayog’s health index placing Bihar at the second lowest rank among all Indian states and a Supreme Court rap demanding some answers from the state government that have been avoided should serve as the wake-up call to formulate a comprehensive, long-term health plan.

 

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Updated Date: Jun 26, 2019 18:20:52 IST