The Bihar government failed at nearly every level to prepare for the annual AES epidemic
The Bihar government’s failure to prepare for the annual outbreak of the Acute Encephalitis Syndrome during the nationwide lockdown has led to the death of eight children in Sri Krishna Medical College and Hospital in Muzaffarpur. AES, known as chamki bukhar locally, is a lethal syndrome that primarily affects young children and toddlers. It is rampant in northern Bihar, particularly in the districts of East Champaran, Sheohar, Sitamarhi, Vaishali and Muzaffarpur. It is an epidemic that has been noted to return nearly every April and May, and has accumulated a death toll of more than 471 in the past decade.
This year, the Bihar government appeared to have done little to prepare for the outbreak and did not take into consideration how the nationwide lockdown to stop the spread of the novel coronavirus would worsen the AES crisis. Despite the annual frequency of AES, the government failed to address the social determinants of AES like malnutrition. The state was also unable to efficiently track cases of the syndrome or create medical infrastructure that could respond to the crisis.
On the intervening night of 24 and 25 April, Sukki Kumari, a four-year-old from Muzaffarpur’s Musahari block complained to her father, Sukhlal Sahni, of fever and nausea. She soon began having violent convulsions and was taken to Sri Krishna Medical College and Hospital in Muzaffarpur and was admitted in the paediatric intensive care unit—or PICU. The medical superintendent informed the family that had her glucose levels had dipped very low. She did not survive the night.
A day later, her twin sibling, Mausami Kumari, who had been admitted with similar symptoms, also succumbed to the syndrome. Their deaths had pushed Sukhlal into inconsolable grief. The contagion had become an indelible part of their village and the ones around them. Less than a month earlier, Aditya Kumar, a three-year-old from Sakra block, became the first to succumb to AES this year. Seven more have followed him during the lockdown, all under the age of ten.
Dr Gopal Shankar Sahni, the head of the paediatric department at SKMCH, said that Sukki and Mausami’s lives could have been saved had they been brought to the hospital earlier. “The twins were brought to hospital ten hours late,” he told me. AES requires rapid intervention after the first symptoms are seen, failing which severe hypoglycaemia—or low blood sugar—sets in, putting the patient in a critical condition. When the infection affects children suffering from chronic malnutrition, a common problem in the region, it greatly increases the likelihood of fatalities. Dr Sunil Kumar Sahni, the medical superintendent of SKMCH, said that on 20 May alone, five children were admitted with severe hypoglycaemia in a critical condition. All tested positive for AES.
Till date there has been no official bulletin where the Bihar government announces the number of AES cases or casualties. The only source of information on the topic is from SKMCH alone, which treats a lot of AES cases, but is unlikely to give a full picture of the situation. Given the strict curbs on movement in place due to the national lockdown it is not clear how many children went uncounted, dying at home or not being identified as suffering from AES.
The Integrated Disease Surveillance Programme, a government initiative under the health ministry’s National Centre for Disease Control, has for several decades tracked diseases across India and released a weekly report of outbreaks on its website. However, following the first cases of the novel coronavirus in India, from early February the IDSP has not released a single weekly report. This makes it tough to calculate the real losses of this year’s AES outbreak in Bihar.
In mid February, the health department of Bihar signed a memorandum of understanding with the Bengaluru-based National Institute of Mental Health and Neuroscience. They hoped the partnership would help establish an enhanced surveillance system to track AES and lend technical support to the state health department in setting up a network of labs to provide diagnostic help. According to Dr V Ravi, the head of the NIMHANS team which was supposed to visit Bihar, they would train two pharmacists and two technicians in every district hospital in identifying AES patients. These newly trained teams would learn rigorous sample-collection procedures and carry out tests, while also building an AES surveillance net for the state. The team from NIMHANS was also scheduled to visit primary health centres in the worst AES-affected blocks and monitor their preparation and response.
However, following the announcement of the nationwide lockdown, no preparation was made for the team from NIMHANS to arrive. Officials from the Bihar health department did not respond to queries on whether the state tried to facilitate their arrival despite the lockdown. Bihar thus entered the most severe phase of the epidemic without any access to expert advice.
In the wake of the recent spate of AES deaths, the Muzaffarpur district administration created two teams to visit the affected villages. After going to Sukki and Mausami’s house, the team concluded that they were malnourished and had slept on an empty stomach before falling ill. According to the National Family Health Survey of 2015, 42.3 percent of children in Muzaffarpur are malnourished. This number is significantly higher for children from Scheduled Caste communities. A study looking at the determinants of AES by the department of community and family medicine of the All India Institute of Medical Sciences, Patna, concluded that in 2019, 123 of the total 200 cases of AES affected members of Scheduled Caste, Scheduled Tribe or Other Backward Class communities. Gopal Shankar, the paediatrician, told me that of the 40 AES cases that came to SKMCH this year, 70 percent of the patients were malnourished.
Along with chronic malnutrition, the lockdown also severely affected accessibility to food in rural Muzaffarpur in the past two months. “The lockdown has completely stopped rations coming into our village,” Shivnath Prasad Yadav, a panchayath official of Rajwara, a village in Muzaffarpur district, said. “Even before, they weren’t frequent. After the death of the twins, the whole village has been given rations but the extra rations we were supposed to get during lockdown has not been given.”
The Bihar government has routinely ignored proposals to address malnutrition in AES-affected districts. On 29 May, I spoke to Dr T Jacob John, a retired professor of virology from Christian Medical College Vellore and the former head of the Centre for Advanced Research in Virology, which works under the Indian Council of Medical Research. He had conducted detailed studies of AES six years ago. “In 2014, I proposed a nutritional enhancement project for Muzaffarpur in form of a food model to government of Bihar with an aim to prevent spread of AES in the malnourished population,” John said. “It was a ‘Dry Food Model’ consisting of puffed rice, jaggery, chana and groundnuts, making their availability mandatory in every house of AES prone areas, with an aim to hinder empty-stomach sleep of undernourished children. It was a feasible procedure to implement against cases and death of AES but the government had prioritised a long-term solution against the menace and so it remained out of practice.”
Failing preventive measures such as a reduction in malnutrition, emergency-response measures are essential in AES affected districts. “Any child with symptoms like fever and seizure first needs treatment at the nearest PHC,” Dr Arun Kumar Shah, the former president of the Indian Academy of Paediatrics Associations, said. “These PHCs need to be well equipped with glucometers, ten percent dextrose infusion, oxygen and nasal spray as anti-convulsant,” Shah told me. Glucometers measure blood sugar and ten percent dextrose infusion is a more potent but easily affordable dosage of regular saline. “Together, all of the rudimentary equipment and drugs required for the emergency treatment of AES are not excessively expensive and only need to be equipped in select PHCs in particularly affected areas. These were our recommendations to the state government but it was not followed strictly.” He continued, “To counter this, we really do need a robust chain of PHCs with trained hands and expertise. During an AES epidemic, treatment delayed is treatment denied, because the early treatment of symptomatic cases is the only way to tackle this.”
The Bihar government revised the standard operating procedure to treat AES-affected children in 2018. The new SOP included an early identification of AES-affected children by accredited social health activists—village-level employees of the government health department. ASHA workers were supposed to provide children at risk of AES with oral rehydration salt packets and direct parents to ensure that toddlers did not sleep on an empty stomach. But in the following year, the state witnessed 440 cases and 161 AES deaths. The audit report of 2019, which the accountant general submitted to the Bihar government, quoted the medical superintendent of SKMCH as saying that malnutrition in children, hot and humid conditions, and low baseline sugar levels were responsible for the AES deaths. The report also blamed the poor fund management because they could not reach the targeted groups in areas such as AES-affected Muzaffarpur blocks for timely treatment. Little, however, has changed since.
The inadequate functioning of PHCs in accordance with the new SOP is an open secret for both medical staff and journalists in northern Bihar. “Every PHC of the district needed to have two-bed paediatric intensive care unit, but due to the COVID-19 scare, they were turned into isolation wards,” a medical staffer at the Motipur block PHC, told me, on the condition of anonymity. “The scarcity of a PICU ward at the local level remains unresolved, worsening the condition of AES-affected patients. During the very first hour of fever and convulsion, the child needs to be administered anti-convulsants and we need a proper PICU facility for this,” the staffer said. The drug stock availability in PHCs also remains insufficient for the emergency care of AES patients.
According to the government’s new SOP, when a child falls ill in a village, she needs to be rushed to the nearest PHC and not to a larger district hospital such as the SKMCH. This is often counterproductive as PHCs are not equipped to handle a case of AES. When Sonu, a four-year-old who was the first AES case in Muzaffarpur’s Motipur block, began showing symptoms, he was hurried to the Motipur PHC. Sonu was given the initial treatment, but the PHC did not have the facilities to deal with his worsening situation. He was transferred to SKMCH in Muzaffarpur the next morning. However, taking him to the PHC had resulted in a loss of two hours of critical care. Sonu has recovered from the AES and is in a stable condition now, but his case highlighted the danger of the new SOP. The lack of well provisioned PHCs means that the new SOP is more likely to harm patients requiring emergency care than help them.
Most AES-affected patients are unable to reach hospitals in time because of the lack of infrastructure in Muzaffarpur. Mangal Pandey, the health minister of Bihar, announced on 9 May that an additional 28 ambulances will be sent to nine districts including Muzaffarpur, East Champaran, West Champaran, Vaishali, Sheohar, Sitamarhi, Siwan, Gopalgunj and Samastipur. The ambulances were to contain kits comprising medical devices to treat AES. This was in addition to the 426 government ambulances already working in these districts. However, the choice of districts showed a lack of planning. Siwan and Gopalgunj districts got ambulances too despite not being AES prone areas. Further, over nine blocks of Muzaffarpur district that are the most severely affected by AES are along the embankment of the Budhi Gandak river, which restricts all large vehicular movement, making the ambulances entirely ineffective. Sukki and Mausami were unable to reach Muzaffarpur in time due to the lack of road connectivity to their village, which meant they had to travel by cycle and then by a motorcycle to reach the hospital.
The designing of the new SOP was largely supervised by Sanjay Kumar, who was then the state’s principal health secretary. However, on 19 May, in the month when the AES epidemic usually peaks, Kumar was suddenly transferred to the state’s ministry of tourism, reportedly because of political disagreements with the chief minister, Nitish Kumar. “There were two major clashes between politicians and Sanjay Kumar,” a senior journalist from Bihar, who wished to remain anonymous, told me. “Firstly, Kumar and Mangal Pandey, the health minister from the BJP had a major tussle over decision making. Also, Kumar was heavily scrutinising a lot of medical officers who lagged in addressing COVID-19 cases, many of whom are close confidantes of Nitish,” he added. Uday Singh Kumawat, who replaced Kumar as the principal health secretary, has no previous experience in the health sector. “Sanjay Kumar knew pros and cons of existing resources and last year’s epidemic crisis was a lesson to all of us,” a state health department official said, requesting anonymity. “Keeping that management in view, his transfer was unexpected.”
With the failure of preventive measures and unprepared PHCs, the entire weight of the AES epidemic is on SKMCH, the largest state-run government hospital in the Tirhut division. The hospital has to manage patients from six districts. I visited its 160-acre campus on 18 March, and it was a study in squalor. When I visited, every third patient was sleeping on floors that were caked in dirt. Families were squeezed into stinking and stained corridors. Mosquitoes haunted every building, breeding in the sewage water that collected in rivulets and puddles as the drainage system lacked any outlets.
Muzaffarpur, with its 28 hospitals, had the highest bed-occupancy rate in Bihar, at 329 percent. The lack of beds was often compounded by arbitrary government reshufflings of wards. When I visited, the management had turned the prisoners’ ward into an ICU and the normal wards into PICUs to accommodate AES patients. Six years after Harsh Vardhan, the union health minister, promised a new PICU, it was finally built this year, with 70 new beds. But it fell far short far short of the patient burden the hospital faced during an AES epidemic. Sunil Kumar, the medical superintendent, had announced that an additional 30 beds would be made functional in the PICU by the end of May. On 6 June, the full 100-bed PICU was inaugurated by Nitish Kumar, but this was after the worst of the epidemic had passed for this year.
Along with a lack of beds, there was also an absence of doctors and nurses at night which was when most AES referrals from PHC arrived. The hospital also had a severe lack of oxygen cylinders. When the city was hit by not one, but two epidemics, the doctor population ration was as low as 80:100,000. Ironically, in 2015, Muzaffarpur had been declared a smart city by the central government.
In June 2014, following the death of 86 children from AES in northern Bihar, Harsh Vardhan visited SKMCH. Afterwards, he tweeted, “Visited hospitals in muzaffarpur to know about children suffering from acute encephalitis syndrome. Really touching moment for me. Research?” Since 2014, the state government has not conducted any research to determine the causal factors of AES or the preventive mechanism for it. “The fact that there is no government-funded research on AES was the first-hand limitation in combatting the crisis,” Shah said. No funds have been allocated for research into the disease either, which has since taken the lives of 157 children.
I reached out to Kumawat, the health secretary, by email and over the phone with questions about the lack of planning for the AES outbreak and the continued lack of research on the disease. His office did not respond to any queries. Other senior officials who I contacted also did not respond to any questions. This year, the Bihar government seemed to have been negligent at every stage of the epidemic response. This points to a continued government apathy to the disease whose primary victims are poor and from marginalised communities and caste groups.