Encephalitis in Bihar: Overburdened primary caregivers, poor quality of health infrastructure add to woes

The last mile of governance is the longest mile of the governance. Over hundread children in Bihar’s Muzaffarpur district have died. The disease medically termed ‘acute encephalitis syndrome’ (AES) is suspected to be the cause of the deaths. It has also spread to adjoining districts like East Champaran and Vaishali. Like every year since it first hit the national headlines in 1995, whodunits doing the rounds have varied.

This year, it’s the toxins in the lychees that are to blame. From state governments to the health ministries, everybody briefly comes under the scanner whenever the disease surfaces in summer. The three primary caregivers are the auxiliary nurse-midwives, who visit villages in addition to providing care at the sub-centres. The second is the anganwadi worker, who works in her respective village and whose focus is provision of nutritional supplements to children, adolescent girls, and lactating women.

The newest cadre is that of the Accredited Social Health Activist (ASHA), whose focus is on promotion of immunisations and institutional-based deliveries, for which they receive a performance-related fee. An interesting study on India’s large-scale community health worker programmes notes that the ASHA payment system fails to reflect the amount and type of work expected. It states that "although ASHA workers are tasked with a wide range of activities, including developing and implementing village health plans, they receive remuneration for only a few activities (primarily bringing in women for institutional deliveries)."

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

Related Articles

AWOL for years, over 60 Bihar govt employees issued notice

Why unwarranted hysterectomies are on the rise in India

The report also pointed out that there are major concerns about the adequacy and quality of training. The training process and manuals have been criticised as knowledge-based rather than skills-based. Last year, at New Delhi’s Jantar Mantar, Firstpost interacted with Anganwadi workers from Uttar Pradesh, Bihar, Madhya Pradesh and Gujarat demanding regularisation and an increase in monthly remuneration.

Priya Dwivedi, anganwadi worker from Panna in Madhya Pradesh, shared that for Rs 5,000, women like her work round the clock for the health ministry, the nagar palika and the Gram Panchayat. She disclosed that these women are being roped in for campaigns on polio awareness or are made to collect Aadhaar data. During the state election in December 2018, Dwivedi was also on election duty.

In September 2018, the prime minister announced an increase in the honorarium for anganwadi and ASHA workers. Those who drew an honorarium of Rs 3,000 started getting Rs 4,500 and those who used to get Rs 2,200 got Rs 3,500. The honorarium of anganwadi helpers was to be hiked from Rs 1,500 to Rs 2,500. In percentage terms, that works out to an increase of 50 percent, 59 percent, and 66.67 percent respectively.

Dr KK Aggarwal, president-elect of the Confederation of Medical Associations in Asia and Oceania and national president of the Indian Medical Association, shared with Firstpost that this year, primary healthcare givers posted at remote areas were on election duty.

“There’s lack of awareness among primary healthcare givers that sub-lingual (spoonful of moistened sugar deposited under the tongue of a young child) can help rescue children,” shared Dr Aggarwal, who was general secretary of the IMA in 2014, when the epidemic took 300 lives. He said that in the following years, the state machinery was better prepared but rued the lack of consistency in skill development and awareness levels among care givers.

“Why are these epidemic outbreaks not treated like disasters? An inter-sectoral approach that enables children being air-lifted to another state, military support and better connectivity of primary healthcare givers with state machinery is badly needed at a time like this,” Dr Aggarwal added.

Japanese Encephalitis was made notifiable only in 2016 after the then health minister JP Nadda talked about the visible failure in tackling the disease in the Lok Sabha in August 2016. But AES is not the same as Japanese Encephalitis and isn’t notifiable. In India, Japanese Encephalitis has traditionally been the most important cause of AES and this has resulted in an overemphasis on parallel AES and JE surveillance. In 2014, the total number of AES deaths from India were 1,717 respectively and deaths caused by JE were 293.

In Dr Aggarwal’s opinion, "this isn’t encephalitis since no virus has been detected". He said that each of the deceased children must go through a post-mortem, which will help the state machinery establish the cause of death. The other problem here is the lack of a strengthened surveillance system for diseases. In the Textbook of Pediatric Infectious Diseases, A Parathasarthy states that all diseases targeted for control must be covered under surveillance.

Systematic epidemiological studies are needed to clearly elucidate the cause, transmission, risk factors and environmental exposures in the spread of the disease. “Healthcare practitioners need to be educated regularly about clinical and non-clinical skills. Currently, these are being done by medical representatives of pharma companies to target doctors to prescribe their drugs,” shared Nilesh Aggarwal, who is the co-founder of eMediNexus, which provides the latest medical updates, interactive content and regulatory updates to over two lakh doctors across India.

Komal Ganotra, director of policy, research and advocacy for CRY (Child Rights and You), said that ever since the launch of the Poshan Abhiyan, the national nutrition mission launched by the prime minister in Rajasthan’s Jhunjhunu district last year, skill development has greatly improved. The stunting caused by malnourishment or anemia in young mothers are both cases where the damage has already been caused.

The problem with malnourishment-related conditions is that weeding out the problem once it has set in becomes a huge challenge. “Farmers have moved towards cash crops and the vegetable and millets intake in the daily diet has gone down. The overall change in the food basket which is now more carbohydrate-driven has had a negative impact on growing children,” she said, adding that the problems range from budgets reaching late to ICDS centres and designated menus not being followed by the centres or anganwadis without any workers at all.

“Nutrition is now high on the political agenda and in the last one year, we have seen a huge change in the skill training aspect because there is a big budget for skill-training frontline staff,” she stated, adding that there’s still a long way to go for building a strong decentralised healthcare framework.

Until serious research attempts and a strengthened surveillance system are put in place, theories about toxins in lychees will come to define the death of children.