Every morning, many of Patna’s school kids can be seen wearing a plastic mask as they board their school buses. By mid-morning, Bihar’s capital resembles a city in camouflage with thousands of motorcyclists riding around with colourful masks strapped to their faces.
“My eyes burn, throat itches and chest heaves. I feel breathless more often than not,” says beauty care professional Radha Paswan, 28. She leaves home at 9 am to be at her workplace by 10. “I rush to switch on the air-conditioner the moment I reach my workplace. It still takes a few minutes for me to start breathing normally,” she says.
Radha, however, is not alone in her sufferings. Bihar is increasingly getting breathless. The latest Bihar Economic Survey for 2018-19 confirms that Acute Respiratory Illness (ARI) accounts for 36.2% of total patients who visited hospitals last year.
No wonder, ARI is the most prevalent disease in Bihar. The Economic Survey, incidentally, is an exhaustive document annually released by the state finance department to map overall performance of various departments.
In terms of numbers, as many as 1.28 million ARI patients were registered in Bihar last year, which was 11% more than the number of patients suffering from fever of unknown origin, No. 2 in the pecking order of main diseases in Bihar.
The body’s respiratory system includes the nose, sinuses, mouth, throat (pharynx), voice box (larynx), windpipe (trachea), and lungs. Upper respiratory infections affect the parts of the respiratory tract that are higher on the body, including the nose, sinuses, and throat, while lower respiratory infections affect the airways and lungs.
“Types of upper respiratory infection include the common cold (head cold), flu, tonsillitis, laryngitis and sinus infection. It is the lower respiratory infections, though, which can be worrisome,” says Dr Ajay Kumar, vice president of Indian Medical Association, Bihar. “It can be caused by bronchitis, pneumonia, respiratory syncytial virus (RSV), severe flu, or tuberculosis. Lower respiratory infection symptoms include a severe cough that may produce mucus (phlegm), shortness of breath, chest tightness, and wheezing when exhaling. Clearly, even minor respiratory issues can be debilitating for a person’s immune system and can lead to complications, if it is allowed to persist.”
“There are multiple reasons for the respiratory issues: pollution from vehicles, garbage burning, road and construction dust, followed by brick kilns they all contribute to it,” he adds.
A comparative study of the figures point towards a very disturbing trend. The number of ARI patients in Bihar has gone up from 690,000 in 2016-17 to 1.28 million in 2017-18, an increase of 290,000 respiratory patients in just one year. “What is, however, more worrisome is the fact that ARI has been at the top of the table of Bihar’s main diseases year after year. We need to do a deeper study to understand the cause and eliminate it,” says a senior health department official.
Dr Ragini Mishra, surveillance officer at the Bihar Health Society, a state government body, explains that ARI numbers have always been high because it also includes cases of common cold. The State Health Society, however, will soon collect a database of patients suffering from pulmonary and other respiratory disorders. Once done, this will be compared to the air quality index to establish what could have caused the disease.
A deeper scrutiny of the figure of ARI patients in Bihar, however, suggests that the usual suspect, air pollution by vehicular traffic, is not the only culprit. In fact, an assessment of patients has confirmed that districts with fewer vehicles have higher number of patients suffering from respiratory illness.
For instance, the district of Vaishali, which annually registers not even 25% of the number of vehicles registered in Patna, reports four times more respiratory cases than those registered in the capital.
Incidentally, of the 1,283,860 patients of Acute Respiratory infection reported in the state last year, Vaishali alone accounted for 126,104 cases. Siwan (94,013), Jamui (90,885), Khgaria (80,212), Purnea (65,254) and Bhojpur (65,027) are the other districts where respiratory illness cases have touched alarming numbers. On the other hand, Patna, said to be the most polluted city with maximum population density in Bihar, had just 20,083 cases of respiratory illness reported last year.
Vaishali, however, does have a higher population share per sq.km. Vaishali is No. 4 in most densely populated districts in the state, with 1,717 persons per sq.km as against the state’s average of 1,106.
“The cause of these alarming numbers, however, is not just the dreaded pollution caused by vehicle fumes,” says Dr Ajay Kumar, vice-president of the Indian Medical Association in Bihar.
“The toxic air that we breathe is the new tobacco. Add to this the unhygienic conditions in Bihar’s rural outback, prevalence of dust and lack of awareness and you have a recipe for disaster,” Dr Kumar adds.
Incidentally, toxic air is already a global menace killing seven million people each year, according to last year’s United Nations Environment Programme report. A majority of these deaths have been reported from the Asia-Pacific region.
Muzaffarpur-based senior pediatrician Dr Arun Shah told India Today that high population density, increasing urban slums and poor sensitivity to health awareness are the major reasons for respiratory diseases. “Remember, viral infection spreads like wildfire. Proactive prevention and timely treatment are just a few ways to win over respiratory illness,” he says.
There are grave threats. Long-term exposure to lung irritants and toxins in the air can cause Chronic Obstructive Pulmonary Disease (COPD) which, according to University of Washington’s Global Burden of Disease study, 2018, was the second highest cause of deaths in India after heart disease in 2017, killing almost 1 million (958,000 to be exact) Indians that year.
COPD inflames airways in the lungs and destroys the air sacs which extract oxygen from the air and expel waste, including carbon dioxide. Patients often cough, wheeze and are short of breath.
In the developed world, a majority of COPD cases are caused by smoking tobacco, but in the developing world, including India, most COPD cases are caused by exposure to indoor and outdoor air pollution, particularly burning biomass, from wood to cow dung.
This could well be the case in Bihar too where a village woman cooks over a dung-fuelled chulha for several hours a day. She could be more exposed to hazardous pollutants than an office worker in Patna.
“The top priority should be to reduce household air pollution from cooking with biomass because the proximity to stove smoke, especially for women and children, makes it most harmful,” says Dr Shah.
But in Bihar’s outback, home to the poor population, people seem less inclined to change their way of life. Chewing tobacco is one of the habits which many in Bihar are unwilling to shun. Researchers have linked smokeless tobacco products also to asthma and other respiratory illnesses. Tobacco users are more likely to suffer from wheezing and night-time chest tightness, chronic bronchitis and chronic nose and sinus problems. Time for Bihar to take note.