Bihar deaths: The Great Indian Survey Trick


Basic health and nutrition services — and not just more data — will help save children’s lives in Bihar

Every time there is a major calamity, look out for those in search of the dumb villain. In Maharashtra, state water resources minister Tanaji Sawant blames crabs for the recent breach in the Tiware Dam in Ratnagiri. In Bihar’s Muzaffarpur, fingers were pointed at the litchi when over 150 children died of acute encephalitis syndrome (AES) last month.

Crabs can’t deny the charges; nor can litchis.

The exact causes of the neurological illness are still unclear but the litchi was not the sole culprit in the AES outbreak. Many other factors, notably a dysfunctional healthcare system, a creaky Integrated Child Development Services (ICDS) and extreme heat conspired against the undernourished children who had gorged on litchis fallen from trees and then gone to bed without a meal.

Almost half of Bihar’s children (48.3 per cent) are stunted or too short for their age, indicating that they have been undernourished for some time, according to the latest National Family Health Survey. A toxin in the litchi triggered reactions among children who were already malnourished, leading to hypoglycaemic encephalopathy.

Bihar has witnessed many outbreaks of AES. This time, a public interest litigation (PIL) suit by two advocates, Manohar Pratap and Sanpreet Singh Ajmani, has brought the matter to the Supreme Court (SC). Both the Centre and the Bihar government are defending themselves with masses of data and new proposals.

The Centre gave the SC a list of measures it would take to address the problem. This includes providing funds for a 100-bed paediatric intensive care unit in Muzaffarpur’s Sri Krishna Medical College.

In its affidavit, the Bihar government catalogued the steps it has taken to address the recurring AES problem in the state, and the proposed measures. It has commissioned a socioeconomic survey of the affected families in the AES-hit areas. It says this would help find a long-term solution to halt the disease.

But is more data — or yet another survey — Bihar’s pressing need?

“Credible data is certainly needed. But, currently, the biggest challenge is not the availability of data. There are already numerous government surveys as well as programme data such as Health Management Information System and others. The biggest challenge is in acting on the data,” says Sulakshana Nandi, national joint convener of Jan Swasthya Abhiyan (Peoples’ Health Movement, India).

The elephant in the room, say Nandi and other health advocates, is the lack of commitment on the part of many state governments in improving healthcare governance and health provisioning in the public sector.

“For instance, a district official is not ignorant about the status of health facilities in the district, but to what extent are they acting on it, or are empowered to act on it? States with strong public health systems such as Kerala have managed to deal with such crises, while in those with a weak public health system, it is the poor and the most vulnerable who suffer the most,” Nandi adds.

Since 2012, a standard operating procedure (SOP) has been in place to deal with AES cases in the state. The SOP, revised last year, lists the steps to be taken — such as tap water sponging, correctly positioning the patient and infusion of adequate glucose — at various levels to manage AES.

The government says in its affidavit that 6,656 copies of a booklet have been distributed to medical college hospitals, district hospitals and primary health centres to spread awareness on AES, and a soft copy of the SOP has been uploaded on the web page of the state health department.

It also points out that of the 12,206 sanctioned posts for medical doctors in the state, including contractual ones, only 5,205, or 43 per cent, are filled. There is also an acute shortage of nurses, auxiliary nurse midwives and laboratory technicians.

The state government says that it has provided gadgets such as infantometers (height-measuring device) and weighing scales to frontline workers to monitor children. Smartphones have been provided for data transmission.

But of the 1,14,718 anganwadi (childcare) centres that are sanctioned, only 99,795 are functional, according to the Bihar government affidavit. ICDS, a centrally sponsored scheme implemented by state governments and union territories, covers anganwadi services. It has the potential to be a nutrition/food safety net for poor families.

But “ICDS is failing the poorest quintile. Our diagnosis is that this is largely because many of the poorest mothers and children in India live in states such as Bihar where ICDS is in particularly poor shape. Despite improvements over time, in 2016, just about 40 per cent of Bihar’s children had received ICDS services,” says Purnima Menon, senior research fellow at the global think tank, International Food Policy Research Institute.

Menon believes the POSHAN Abhiyaan (National Nutrition Mission), launched last year, has a huge role to play here. “What is urgently needed is that the national efforts around POSHAN Abhiyaan push hard for Bihar to get the basics right in the context of their ICDS services — infrastructure, human resources, provision of food, other ICDS programme services — to all target beneficiaries,” she says. “If the basics are working, then the programme can do more in a crisis period. But if the basics are not in place, it’s going to be very difficult to respond in a crisis.”