Journalism of Courage
Every year around this time, when temperatures in Muzaffarpur cross the 40-degree-Celsius mark, the district begins counting its losses from the deadly Acute Encephalitis Syndrome (AES). This year, there have been 560 confirmed cases of AES, with over 120 children dying of the disease in Muzaffarpur alone, a staggering rise from the seven deaths in the district last year. Most of the deaths have been reported from three blocks in Muzaffarpur — Mushahari (12 deaths), Minapur (14) and Kanti (14).
SKMCH, the biggest government hospital in the district, has witnessed over a thousand AES deaths since 2011, almost all of them children. This year, the hospital has already reported 128 deaths since the beginning of June.
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Experts have been blaming the AES deaths on ‘3G’ — Garmi, Garibi and Gaon, or Muzaffarpur’s heat, poverty and certain distinct epidemiological features, which ensure AES cases almost stop with the first rains.
Dr Arun Shah, executive committee member of the Indian Academy of Pediatrics, says, “AES occurs mostly among children below 10 years. In most cases, malnutrition is the common factor. Hypoglycaemia (low sugar levels) is another common thread.”
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After the recent visits of Bihar Chief Minister Nitish Kumar and Union Health Minister Dr Harsh Vardhan to SKMCH, the health department called upon Primary Health Centres (PHCs) and Community Health Centres (CHCs) to lead the charge. All PHCs and CHCs, the government said, should have devoted AES wards, each with at least two beds. These wards, with oxygen cylinders and glucometers, have to be airconditioned. They have been told that they must treat AES patients, not just refer them to SKMCH and other bigger hospitals.
Explained | What causes AES? What makes Bihar so vulnerable?
Despite this mandate, PHCs and CHCs, often woefully short of both medical and non-medical staff, find themselves with their backs to the wall. The Sunday Express visits three PHCs/CHCs in the worst affected blocks of Mushahari, Minapur and Kanti.
Doctors: 5 (13 posts)
ANMs: 60 (full strength)
Pharmacists: 1 (6 posts)
Lab technicians: 1 (6 posts)
Dresser: None (no posts)
Compounder: None (no posts)
Oxygen cylinders: 3
Oxygen concentrator: 1
Glucometer: 5 sets
Pathology tests done: Complete Blood Count (CBC), HIV, kala azar, tests for malaria, sugar levels
It’s 9 am, an hour since the Out Patient Department (OPD) at the Mushahari PHC was opened to patients, but the doctors are not in yet. Around 20 patients, mostly women and children, queue up outside one of the seven rooms in the OPD, the only one that will open, they have been told.
Outside the PHC, a worker is trying to fix a microphone atop an ambulance. After a few failed attempts, he manages to fix it. The ambulance is being readied for a round of villages in Mushahari, a block in Muzaffarpur district, to raise awareness on AES. The ambulance workers have also told to be on call for any emergency and bring in patients who call with fever, vomiting and convulsions, key symptoms of AES.
AES has struck Muzaffarpur during summers since 1995, with the disease claiming the lives of nearly 1,000 children between 2010 and 2014. While doctors have identified malnutrition and low sugar levels as a common thread among all AES patients, the state of the district’s PHCs and CHCs make the battle against AES doubly harder.
The three-storey building is proof that the AES battle begins at the doorsteps of PHCs such as this one. While the building is swanky, complete with a glass facade, the centre faces a crippling shortage of staff. The six-bedded PHC was recently shifted to this new building that was meant for a Community Health Centre (CHC), but it hasn’t been upgraded to CHC status yet (a PHC has six beds, a CHC 30). During his visit to Muzaffarpur, Union Health Minister Dr Harsh Vardhan announced that every PHC would now have 10 beds.
“Mushahari block has a population of about four lakh. According to rules, there should be a doctor per 1,000 population. We should have at least three-four paediatrician, an orthopedician and a surgeon. But we only have one pediatrician and he is on deputation. We have a general physician, but if a PHC has to take the load off hospitals, it must have specialists,” says a hospital staff requesting anonymity.
The PHC’s only pediatrician, Dr Rajesh Kumar, has been on deputation at the AES ward of Kejriwal Matrisadan, a trust-run hospital in Muzaffarpur that has reported 20 AES deaths so far.
The PHC has separate wards for men and women and a room for ASHA workers (Accredited Social Health Activists) — all of which are shut. Rooms for the medical officer and the block health manager are also under lock and key. PHC staff say these positions could be filled once the centre is elevated to CHC status.
By 9.30 am, gynaecologist Dr Priti and general physician Dr Parbeen begin attending to OPD patients, mostly children.
At the AES ward on the first floor, two Auxilliary Nurse Midwives (ANMs) have been tending to two children admitted with suspected AES. “We have administered them saline. Their blood sugar levels are under control,” says one of the ANMs.
No doctor has visited the AES ward yet this morning. The air-conditioner hums softly. There have been clear instructions to ensure functioning air-conditioners in AES wards.
Flipping through the admission register, the ANM says, “Since the AES outbreak this season, we admitted 18 patients, of whom three were discharged, two are under treatment here and the others have been referred to SKMCH and Kejriwal Matrisadan.” “All the children we referred to bigger hospitals had recorded blood sugar levels below 30 mg/dl. Anything less than 50 mg/dl has to be flagged,” she says.
Ganiya Devi’s two-year-old grandson Ravi is one of two patients inside the AES ward. “On June 19, Ravi got seizures and fell unconscious. That’s when we got him here,” she says.
Devi lives in Motipur, 3 km away, with her daughter and grandson. “I can barely manage two meals for the three of us. The night he fell sick, my son only ate half a slice of bread,” she says.
“She brought the child just in time. Patients are supposed to be brought preferably within two hours of the onset of convulsions, with or without fever” says the ANM.
There is sudden activity at the AES ward as a Unicef team arrives at the PHC. As he walks in, Dr Asadur Rahman, chief of field office at Unicef Bihar, takes exception to the presence of “too many people” in the AES ward. Dr Syed Hubbe Ali, who is also part of Unicef’s team, says, “Unicef has suggested to the state government that it must distribute glucose biscuits among poor people. We have observed that 82 per cent AES admissions happen during early mornings, which suggests that patients had gone to bed without food, making their sugar levels dip.”
Just then, Muzaffarpur deputy collectors Pratima Sinha and Renu Kumari visit the PHC. They have been deputed to ensure ORS packets are being distributed and the awareness campaign is being carried out.
At 1.30 pm, with half an hour left for the OPD to wind up, there is still a steady flow of patients. “We just hope the rains come fast, AES cases subside and our lives will get back to normal,” says a hospital worker, directing a patient to the OPD.
Read more | As AES claims seven in Bihar village, many leave with children
Doctors: 1 (4 sanctioned)
Contractual doctors: 1
ANM: 34 (36 posts)
Pharmacist: 1 (1)
Dresser: None (1)
Health servant: 1 (3 posts)
Oxygen cylinders: 3
Oxygen concentrator: 1
Glucometers: 3
Pathology tests done: CBC, sugar levels, kala azar, malaria
Dr A K Pandey doesn’t hide his irritation every time the door to the AES room swings open. “Please shut the door. The AC is on,” he says every now and then.
Pandey, who is the medical officer in charge of the Minapur CHC, has posted himself at the AES ward, where two children are admitted. He says the CHC has so far distributed 56,000 ORS packets. “But we have population of 3.8 lakh in Minapur block and we need a lot more. We have to ideally give four packets to each family,” says Dr Pandey. There have been frequent inspections these days and he is ready with most answers.
Since the beginning of this month, the centre admitted 14 children with symptoms of AES, of whom 12 were referred to SKMCH. The other two are under observation.
Of the 14 children who died of AES in Minapur block — as confirmed by District Malaria Officer Dr Satish Kumar — none was first brought to the CHC. “We still need to inspire people to come to us first rather than visiting quacks. In a lot of cases, the patients were brought in only after their condition deteriorated substantially. Our job is to stabilise patients and refer them to SKMCH. We are slowly growing in confidence while dealing with such cases,” Pandey says.
Indu Devi’s 10-month-old daughter Nandini was admitted this morning with high temperature and dipping sugar levels. Dr Pandey says the child is stable now. On another bed is Abhay Kumar, 7, who was admitted after complaints of vomiting. Both patients will be kept under watch, says Pandey.
“AES is called chamki bukhar in these parts because the fever comes with convulsions. But a distinct feature of AES this year has been that not all patients are reporting fever,” says Pandey.
The AES door swings open once again and two men walk up to Pandey. They introduce themselves as doctors from Supal — anaesthetists Deepak Gupta and Nilesh Pradhan. They are here under orders from the health department.
“They should have sent paediatrician, but at least we have some extra hands in this crisis situation,” says Pandey, while assigning the doctors some work.
The CHC, which makes do with just one doctor against a sanctioned strength of four, makes do with doctors on rotational duty from additional PHCs under it.
“Though we do institutional delivery, we have no gynaecologist here. So in case of complications in delivery, the male doctor has to step in. Not all patients are comfortable with that. Elevating a PHC to CHC status is not enough; the government has to give us more staff,” says a hospital official.
Dr Pandey has just been alerted about a visit by Muzaffarpur DM Alok Ranjan Ghosh. No sooner than he steps out of AES ward, the DM and other health officials enter the CHC.
“Your mandate is not just to stabilise AES patients and refer them to bigger hospitals. You have to ensure that you fully treat as many AES patients as you can. Take all cases to their logical end, diagnose them,” he says as Pandey makes brief interjections.
DM Ghosh tells Pandey not to let ambulances stay idle at the CHC. “Station them near market places and let them make announcements on AES awareness. They must bring all suspects here,” says the DM.
The CHC, which had two ambulances, got three more over the last two days. Two ambulances have been sent out to be fitted with ACs. Two are bringing children from villages nearby. “This is like a mission to flush out AES. Even children with mild fever are being brought to the CHC. Had we done this before, we could have saved several lives,” says a hospital employee.
Doctors: 4 (7 posts)
Nurses: None (7 posts)
Dresser: None (1 post)
Lab technicians: 2 (8 posts)
ANM: 64 (77 posts)
Pharmacists: 1 (8 post)
Oxygen cylinders: 3
Glucometers: 4
Pathology tests done: CBC, Kalazar, Malaria and sugar
It is 3 pm and Dr Umesh Prasad Choudhary, the medical officer in charge of the CHC, has been busy all day — shuttling between the AES ward and the administration department to coordinate with visiting doctors and experts. With Kanti among the worst-hit blocks, reporting 14 AES deaths since the beginning of this month, the CHC and Choudhary have felt the pressure.
Since the first week of June, the hospital admitted 21 patients with suspected AES, of whom 10 had to be referred to bigger hospitals in the district.
An A-4 size paper stuck on a door announces the AES ward, where two patients have been admitted — two-year-old Priyanshu Kumar and nine-year-old Suruchi, who were brought in with fever and convulsions.
Priyanshu’s father Vishnu Ram, a daily wager earning Rs 300 a day, says, “When my son fell sick, I was in two minds — whether to take him to SKMCH or here. Since the CHC was closer, I rushed him here. I am happy this hospital could save my child,” says Vishnu, who says he got Rs 400 as conveyance allowance that the government recently announced for AES patients.
“The child’s blood sugar had dipped alarmingly to 21 mg/dl. Had there been a delay of even 15 minutes, the child would not have survived. His sugar level has risen to 88 mg/dl now,” says Dr Amit Kumar, one of the two doctors in the AES ward, both general physicians on deputation. While Kumar is from Madhubani, Dr Shahid is from Darbhanga. They are joined by Dr Ajay Kumar Singh, a pediatrician who runs a private clinic in Bhagalpur and who is here to volunteer.
The centre, which caters to about 3.8 lakh people, has just four doctors against a sanctioned strength of seven. There is no gynaecologist or any other specialist doctor. There is no regular nurse either. There have been no appointments to the seven contractual posts of nurses. The SHC depends on 64 ANMs, who work in shifts and also do field visits.
Back in the AES ward, Dr Amit Kumar says, “There should be a nurse posted permanently at the AES ward. Are we now expected to inject patients too?”
A hospital staff says, “They have given us a building, but we desperately need doctors and support staff. The administration should have foreseen the crisis and sent doctors from outside in May itself. It’s only now that they are pressing the panic button.”
On the first floor of the hospital is an empty general ward. The ward for women has only two patients.
Outside the CHC stand three ambulances, besides a three-wheeler droning on with instructions on how to tackle AES. “Shouldn’t they be making these announcements outside the centre,” says a visitor to the CHC.
