As per media reports, 172 children have died in the space of three weeks in Muzaffarpur, Bihar. This is higher than the 122 deaths recorded in the 2014 outbreak. Clearly, no lessons seem to have been learnt. This is unacceptable and the media outrage is justified.
A similar tragedy occurred at Gorakhpur, Uttar Pradesh in 2017, when over 600 children reportedly died of Acute Encephalitis Syndrome (AES). Now, in Muzaffarpur, AES is once again in focus. The Lancet Global, a leading and authoritative medical journal, published a study analysing the 2014 deaths in Muzaffarpur.
The findings were disturbing: The case fatality rate was 31 per cent; 55 per cent of the sick children were boys with three quarters of them below four years age; the case patients’ measurements showed that 16 per cent of them were “wasted” and 65 per cent “stunted” (due to chronic hunger). Drawing from the detailed examination of the case records, blood tests, socioeconomic profiling, etc, the experts concluded that the plausible — not necessarily sufficient — causal pathway to deaths could have been litchi consumption on an empty stomach, causing hypoglycemia, requiring treatment. The study concluded that three steps need to be taken to prevent such deaths: Reduce litchi consumption by children during the peak season; ensure consumption of the evening meal; and in suspected cases requiring treatment, ensure a rapid glucose correction.
The Lancet study, along with the evidence of AES around Muzaffarpur, brings out three unacceptable factors: One, the continued lack of clarity on the direct and distal causal factors that should and could have been addressed on priority, enabling the formulation and enforcement of protocols for prevention and treatment. This is particularly saddening since within a space of five years, we have had at least four outbreaks of child deaths in Bihar and UP — 2014, 2016, 2017 and now 2019 accounting for over 1,700 children dying needlessly.
Two, the children who died were all from poor families whose poverty status was multidimensional — unclean habitation, poor housing, overcrowding, hunger and illiteracy. The recent case has two more important points to be noted. Eating litchis per se is not the cause: Eating unripe, rotten litchis, from the ground and partially consumed ones, followed by no meal are. It does not require much imagination to understand the typology of the children who eat such type of litchis and “skip” evening meals. One article suggested that the enquiry showed that some of the deceased children had no food for three days. So, the causal factor is clearly poverty-associated hunger and dietary practices.
The third factor is the collapse of the primary healthcare system. Bihar does have a legacy issue. Healthcare in general and primary care in particular has been severely neglected in the past. The 52nd Round of the NSSO had clearly shown that 22 of the 33 million people impoverished due to health expenses were from the four northern states of rural UP, Madhya Pradesh, Bihar and Rajasthan. This was the justification for the NRHM initiative. The improvements in rural healthcare resulted in Bihar reducing its IMR from 60 per 1,000 live births in 2005 to 38 and maternal mortality is 165 per 1,00,000 births in 2016. Even as the agenda of revitalising a moribund primary healthcare system is unfinished, policy attention shifted to non-communicable disease control and hospital insurance. These are misplaced priorities as the disease burden of Bihar, as per the ICMR study of 2015, shows that communicable diseases alone account for 43 per cent of the disease burden — others being non-communicable and chronic diseases which too can be largely prevented and require to be diagnosed early and managed in primary healthcare settings. Significantly, 70 per cent of deaths are premature, with almost 30 per cent of them among children under 14 years, while the top four causal factors of mortality are malnutrition, air pollution, contaminated water, poor sanitation and poor diet — high levels of anemia.
These risk factors which provide a home to virus and bacteria, again require to be addressed at the household/community levels by primary healthcare workers. Preventive measures and simple treatments like providing glucose correction can be done in PHCs and community centres at the block level. Thus, while the condition of district hospitals — without basic equipment and adequate skills is unacceptable and require to be improved without delay — adding 1,500 beds is not the answer. As the Ebola experience of Sierra leone and Liberia conclusively demonstrated, constructing big hospitals at great expense was not what contained the epidemic, strengthening community health did.
The nation-wide anger of the junior doctors and of people in Muzaffarpur is a wake up call for country’s political leadership to go beyond rhetoric. Infectious diseases know no boundaries and are unafraid even of the powerful. Containment of these diseases requires waging a war against their underlying social determinants — clean air, water, sanitation and nutrition and access to primary healthcare.
This is not a choice but an imperative and a fundamental pre-requisite for development. Economists advising governments on achieving growth need to appreciate this factor, one that several other countries have long understood. Growth needs to be measured not in GDP terms nor on ease of business, but on longevity of life, ease of living, productivity, well-being and innovation. To drive home this point, that countries like India continue to deny, the World Bank developed the Human Capital Index showing that the drivers of growth are education and health: A fact that the Commission on Macroeconomics and Health chaired by Jeffrey Sachs noted in 2000. Under the HCI, India ranks 115 out of 157 countries.
Health is a political question. It is time that the political leadership collectively agrees to set aside partisan acrimony and adopts a zero-tolerance policy to any laxity on matters related to health. It is time that leaders decisively demonstrate that they care and that every life counts.
Rao is former Health Secretary, Government of India and author of Do We Care? India’s Health System