AES in Bihar: A case of rural healthcare in crisis

Source: downtoearth.org.in

The recent outbreak of acute encephalopathy syndrome (AES) in Bihar, which claimed lives of more than 170 childrenportrays a crippling rural healthcare system grappling with shortage of health providers and proper infrastructure.

The brain fever in Bihar has not established as encephalitis at the moment, hence its called encephalopathy — ‘itis’ indicates that the syndrome is an infection, while the cause is yet to be ascertained ‘pathy’, on the other hand, indicates that the cause is unknown.

Acute encephalitis syndrome, on the other hand, is a broad term and includes viral infection (encephalitis) and hypoglycaemic encephalopathy — low sugar levels as a result of malnourishment and lack of proper diet. 

AES is a brain fever that gets manifested in the form of seizures and needs to be treated speedily — time plays a crucial role in reducing mortality rates.

“The onset of AES is not from seizure but alteration in brain, which causes fever and begins much early. A pateint may have four hours from there till the onset of seizures,” said Shefali Gulati, a specialist in child neurology at AIIMS-Delhi.

“The beginning of seizures indicates that the brain is swollen. A child must reach a health facility within five-seven minutes of the seizure, for the treatment to be effective,” Gulati said.

“The primary healthcare centres (PHCs) must be stocked abundantly with anti-convulsant drugs, IV fluids and other necessary drugs for correction of hypoglycaemia (low blood sugar)in AES-affected children,” she told DTE.

Claims vs reality

In a bid to curtail the disease, the Bihar government had in 2016 prepared a standard operating procedure (SoP). It was subsequently revised in 2018. The SoP clearly mentions that PHCs have to be prepared with anti-convulsant and other drugs. It defines role of PHCs, community health centres (CHCs), district hospitals as well as medical college hospitals.

While the Bihar government claimed adequate preparation in accordance to the SoP, Down To Earth (DTE) found stark difference between ground reality and the claims made.

In early June, Vijay Kumar from Bahadurpur village of Muzaffarpur district arrived at the PHC in Kanti block, with his son who was convulsing. But his son was refused admission in the PHC. Kumar then had to take him to Sri Krishna Medical College and Hospital (SKMCH) in an auto, where he later died.

“My child was convulsing badly, his face had deformed and was unconscious. We had absolutely no idea as to what was happening. But the compounder in this very PHC refused to admit him saying he would not be able to do anything. Had the doctors here helped, I would have perhaps saved my child,” Kumar rued.

Kumar is yet again at the PHC with his ailing wife, who however, has been admitted.

The PHC has a ward dedicated for AES and has two beds. Kumar, however, claimed that the ward came into existence much later after the deaths peaked by mid-June.

Muzaffarpur has borne the brunt of the deadly fever with more than 100 deaths and 544 cases. Kanti is one of the four most affected blocks of the district.

Suraj Das from Jamalabad village of Muzaffarpur’s Meenapur block narrated a similar story. Das told DTE that there was nobody in the PHC, when he came with his four-year-old child, early in the day.

It may be mentioned here that the children with AES fall sick between 4 am and 7 am in the morning, and it is the only time of the day when there is even a chance of getting a healthcare provider in the PHC, as less than one-fourth PHCs in Bihar run around the day, according to a Niti Ayog report. 

While both Kumar and Das tried going to PHCs, others did not, owing to poor experiences earlier. There were also cases when medicines ran out of stock in the PHCs.

“We don’t have faith on PHCs because they are never functional. We prefer to take our children to the SKMCH,” Mohammad Sharif Alam of Madhopur Machhia village, Muzaffarpur who lost his four-year-old son, told DTE.

Poor infrastructre

More than 70 per cent PHCs, out of 2,012 PHCs in Bihar, function without a medical officer and a nurse. Hence, they have been deemed non-eligible for any grading, according to the Union health and family welfare’s Health Management Information System (HMIS) for 2018-19. The mandatory criteria for considering a PHC eligible for any grading is at least a medical officer and a nurse.   

In Muzaffarpur alone, 98 out of 103 PHCs were found unfit for grading while another five, which were found fit for grading, scored zero (based on availability of laboratory services, ambulance services, OPD rooms and availability of drugs and other supplies) on a scale of five. Sitamarhi’s 45 PHCs out of 57 were ineligible and East Champaran’s 83 out of 102 shared the same condition.

In the case of CHCs in Bihar, only 19 per cent got a grade above four (based on immunisation and family planning methods) in 2017-18, decline of one per cent point from last year. 

Bihar is also infamous for not being able to spend a large part of funds provided under the National Rural Health Mission.

The Bihar government took 191 days in 2017-18 to transfer the fund from state treasury to implementing agency, according to Niti Ayog. This is the highest across all over India. In Uttar Pradesh, the corresponding figure was 118.

Lack of human resource

Besides crippling infrastructure, Bihar also faces shortage of health providers.

Unavailability of doctors is the biggest problem grappling the state. In 2017-18, the state had only 3,679 doctors, against the sanctioned number of 9,558, according to the Bihar Economic Survey 2018-19.

Worse, instead of adding, the state is also witnessing a decline of doctors: Bihar had 4,106 doctors in 2016-17. 

The state has only 2,508 nurses, against the sanctioned posts of 6,423; 19,901 ANMS (Auxillary Nurse Midwives) against the sanctioned posts of 34,446.

This comes at a time, when the state government is in a bed-increasing spree for its medical college hospitals.

After the AES outbreak this year, chief minister Nitish Kumar announced to increase the bed strength in SKMCH to 1,500 from 610.

The government has also decided to increase up to 5,000 beds from the existing strength of 2,500 in Patna Medical College and Hospital, the biggest hospital of the state.

“This is absurd. When all indicators say that they have to put stress on improving rural health infrastructure, their entire stress is on increasing tertiary care. Moreover, from where will they get doctors? The state has not enough doctors to serve current government health facilities,” Ranjit Kumar, an office bearer of Bihar State Health Services Association, told DTE

“This is so because the recruitment of doctors on regular posts in government sector takes ages in Bihar, but even those working in government sector do not get promotion in time. Why would doctors want to stay in in Bihar then,” he added. 

The announcement by CM Kumar is also seen as a knee jerk-reaction in the wake of current outbreak as the deadline seems unrealistic. 

“It is impossible to do it in one year time and it would take a minimum of two years. It takes two years to convert a 6-bedded PHC to 30-bedded CHC, so how would it be possible to convert 610 beds to 1,500 in a year,” a senior health official told DTE, on condition of anonymity.

In Bihar’s Darbhanga hospital, 50 kids die within one month

Source: dnaindia.com

A month after 170 children died in Bihar due to Acute Encephalitis Syndrome (AES), 50 children have been reported to have died in Darbhanga Medical College and Hospital (DMCH) in a month’s time. According to a report prepared by the Child Department of DMCH, 50 children died in the hospital during the period from June 01 to June 30.

The hospital authorities came in for a shock when they learnt about the report. However, Superintendent Dr Raj Ranjan Prasad seemed to make a casual affair out of the tragic incident. Commenting on the alarming number of children deaths, he said, “Deaths occur every year when children are admitted to the hospital. However, this time the total number of deaths is a lot more than previous ones. We will have to see if proper treatment was given to these children. We have asked the concerned authorities to ascertain the cause of these deaths, he added.” Reports suggest that DMCH got timely help from UNICEF too.

Nitish Kumar led JDU government in Bihar has filed an affidavit in the Supreme Court regarding falling health standards in the state. But the opposition parties have left no stone unturned to criticise the opposition. While BJP MLA Gopal Narayan Singh said that the health conditions in the state have not improved since the time Lalu Prasad Yadav was the Chief Minister, leader of opposition Tejashwi Yadav said, “During the said 14 years of good governance under Nitish Kumar in Bihar, the posts of 47% doctors, 71% nurses, 62% lab technicians and 48% of pharmacists have been vacant.

In addition, Former CM Rabri Devi accused the government of doing drama. She said, “The government has been playing politics over the deaths of children due to AES and distributing mangoes in the assembly whereas the conditions continue to be pathetic in hospitals. There are neither adequate doctors nor beds.”

AES in Bihar: Providing all support to contain it, Centre tells SC

Source: business-standard.com

The Centre told the Supreme Court Wednesday that it was proactively providing all support to Bihar in containing and managing Acute Encephalitis Syndrome (AES) in which more than children have died.

In an affidavit filed on a plea seeking measures for containment of the disease, the Centre said Union Health Minister Harsh Vardhan had visited Bihar on June 16, to review the situation in Muzaffarpur.

It said that after the visit several decisions were taken including construction of a 100 bed Paediatric Intensive Care Unit (ICU) at SKMCH hospital in Muzaffarpur by the state government in one years from the funds of National Health Mission (NHM).

“The land for the same (100-bed Paediatric ICU) is available in the premise of the SKMCH hospital and will be provided by the state,” the affidavit said.

It said a decision has been taken to set up five virology labs in different districts of the state from the NHM funds and the location of the districts will be decided in consultation with the state government.

Detailing further decisions taken, the Centre said: “In the adjoining districts, 10-bed Paediatric ICUs to be setup so that such cases can be treated early and there is no unnecessary load on the facilities available at SKMCH. Funds for this are to be provided through NHM.”

The ministry said that to enable early detection and treatment of the hypoglycemia cases, a dedicated team of doctors will be placed in endemic Primary Health Centres with required facilities, at least for three-four months before and during expected onset of disease.

“As for present, the concerned PHCs and CHCs (Community Health Centres) should take prompt corrective measures for hypoglycemia at the facility itself to utilize the golden hour”, the affidavit said.

It said that a Super Speciality Block is being constructed at SKMCH hospital, Muzaffarpur and it would start functioning by first week of December.

Besides these steps, the affidavit said that Ministry of Earth Sciences has been requested to upgrade its IMD Observatory facility for improved monitoring of climate related parameters such as temperature humidity, rainfall and share it with the state government for better preparedness and management of AES.

It said the minister has decided to constitute inter-disciplinary, high quality research team for ascertaining the case of AES with specific reference to Muzaffarpur.

“The vacant positions of district epidemiologist and entomologist in Muzaffarpur to be filled up immediately by the state government,” the health ministry said added that health is a state subject as per the Constitutional provisions.

The apex court is hearing a petition filed by advocate Manohar Pratap who has said that he was deeply “pained and saddened” by the deaths of more than 126 children, mostly in the age group of one to 10 years, in Bihar due to AES.

Besides Centre, the apex court had also asked Bihar government to file its response on the issue.

In a shocking revelation about medical care facilities in Bihar, which is facing an outbreak of acute encephalitis syndrome, the state government Tuesday told the Supreme Court that there are only 5,205 doctors in government-run health centres against the sanctioned strength of 12,206.

The state government, in an affidavit filed in the apex court, said that only 5,634 nurses were there in government run hospitals and health centres against sanctioned strength of 19,155.

The court had on June 24 directed the state to apprise it about the status of public medical care facilities, nutrition and sanitation within a week in view of deaths of over 100 children in Muzaffarpur due to the outbreak of AES.

Regarding AES cases, the state government said 824 cases have been reported and the number of deaths was 157.

It, however, said that it was not known whether 24 deaths out of 215 cases were due to AES.

“State of Bihar had already taken all possible steps to prevent the spread of the disease by providing additional medical facilities at the affected region, public awareness campaign at the village level, involving various agencies to assist the government etc,” it said.

Symptoms of AES include high fever, convulsions and extremely low blood sugar levels. Among the factors said to trigger the syndrome are malnutrition.

There were more than 44,000 cases and nearly 6,000 deaths from encephalitis in India between 2008 and 2014, said a 2017 study published in The Indian Journal of Medical Research (IJMR).

Researchers said the patients often report acute onset of fever and altered consciousness, with a rapidly deteriorating clinical course, leading to death within hours.

Litchis grown in Muzaffarpur, the country’s largest litchi cultivation region, are said to contain a toxin which can cause a drop in blood sugar levels if consumed by a malnourished child.

Tejashwi Yadav finally surfaces in Patna but still can’t make it to Bihar assembly

Source: theprint.in

Patna: Under fire for the Rashtriya Janata Dal’s (RJD’s) dismal campaign in the Lok Sabha elections, Tejashwi Yadav is still to return to the political arena even though he was back in Patna Sunday evening after spending a month in New Delhi.

Yadav’s absence is all the starker as he is the leader of opposition in the Bihar assembly, where the monsoon session commenced Friday. On Monday, the treasury benches allowed a rare adjournment motion on the death of around 180 children in Muzaffarpur due to the Acute Encephalitis Syndrome (AES).

Adjournment motions are an opportunity for the opposition to censure the government on its lapses, but Tejashwi, the son of RJD chief Lalu Prasad Yadav, wasn’t present in the House despite his home in Patna being less than a kilometre from the assembly building.

That prompted Parliamentary Affairs Minister Srawan Kumar to gesture at Tejashwi’s empty chair even as Speaker Vijay Choudhary remarked, “Let’s focus on the members who are present”, leaving RJD MLAs red-faced.

“This must be the first time in parliamentary history that the leader of the opposition has been absent on such an important issue,” an angry RJD MLA later told ThePrint.

The onus was then on a few senior opposition leaders such as Abdul Bari Siddiqui of the RJD and Sadanand Singh of the Congress to grill the JD(U)-BJP government on the issue but they targeted Health Minister, the BJP’s Mangal Pandey, as opposed to Chief Minister Nitish Kumar.

The Nitish government has been pulled up by the Supreme Court and the media over the Encephalitis deaths but was virtually handed a walk-over in the assembly as the opposition allowed Pandey to read out the steps taken by his department without questioning him.

Family, party unsure of whereabouts
Tejashwi had gone off the radar after addressing a press meet in Patna on 28 May following the Grand Alliance’s defeat in the Lok Sabha elections. There was much speculation on his whereabouts with some RJD leaders even claiming that he may have gone to London to watch the Cricket World Cup as he is a former cricketer himself.

On 28 June, exactly a month later, Tejashwi tweeted accusing the media and his political opponents “of cooking up spicy stories” of his absence and stating that he was away as he had an anterior cruciate ligament (ACL) injury.

He then went on to reiterate his party’s “commitment to the poor” and added that he was “following up on” the death of children due to Encephalitis.

But there is little clarity on his whereabouts, with family members showing irritation when asked the question. Tejashwi’s brother Tej Pratap surfaced in the assembly Monday but shrugged off the question. “He must be at his home,” Tej Pratap said. Their mother, former chief minister Rabri Devi, Friday snapped back at a reporter over the same question. “He is at your home,” she said.

RJD MLAs, however, told ThePrint that Tejashwi was yet to interact with them. “When a few MLAs telephoned him they were told that he would call back. But that call never came,” a senior RJD MLA said, adding that the party was yet to hold its routine meeting of legislators to discuss its floor strategy for the monsoon session.

“The result is that in the assembly we are going soft on CM Nitish Kumar, but in the state legislative council, Rabri Devi is demanding his resignation,” he added.

Opponents mock RJD leader
NDA leaders have been taking jabs at Tejashwi ever since his tweet on 28 June.

“Arun Jaitley and Sushma Swaraj made their illness public while they were in office,” said deputy CM Sushil Kumar Modi. “Tejashwi Yadav made his absence mysterious and has disrespected his party and its legislators.”

The RJD leader is also facing flak from his own party colleagues. “The manner in which he runs the party raises questions on if the party will survive. He refuses to meet his supporters and leaders,” said another RJD leader. “All this is happening when the party has to gear up for the assembly polls next year.”

The leader further said that Tejashwi is living up to his reputation as a “non-serious political leader who did not even cast his vote in Patna during the Lok Sabha polls”.

Posters in Patna blame Nitish, Pandey for AES deaths

Source: nationalheraldindia.com

Hours ahead of the Monsoon session of the Bihar Assembly on Friday, posters appeared in Patna blaming the NDA government for the death of over 150 children in Muzaffarpur due to Acute Encephalitis Syndrome (AES) and the complete collapse of law and order in the state.

Dozens of posters in Hindi that were pasted on walls along the main roads in the state capital, also demanded resignations of Chief Minister Nitish Kumar and Bihar Health Minister Mangal Pandey on moral grounds for having failed to check the spread of AES.

The posters termed Bihar as “maut ka kuan” (death well) and mocked it leaders lack of concern for the suffering of the people of the state.

“Chief Minister Nitish Kumar found time to visit Muzaffarpur only after 100 children had died, while Mangal Pandey was more interested knowing the score of the India and Pakistan World Cup cricket match at his press conference with Union Health Minister Harsh Vardhan in Muzaffarpur,” it said.

The posters also expressed growing resentment among the people over the rising lawlessness in the state with daily reports of murder, kidnapping, extortion, loot, robbery and rape.

Ealier similar posters had come up in Muzaffarpur — the epicentre of AES epidemic — asking people to trace “missing” Opposition Rashtriya Janata Dal (RJD) leader Tejashwi Yadav.