Public Health in India– Lessons from Bihar

Public health has been a major concern for a populous country like India. Even today, we are struggling to fight seasonal outbreaks of fevers and other communicable diseases. Specifically, the recent times have been quite serious with respect to child health with the outbreak of brain fever in Bihar. In this backdrop, the efficiency of our public health services comes into question because these outbreaks are often the consequence of the lack of basic health infrastructure. Though we have made substantial progress since independence, it has time and again proven to be insufficient. The management of the outbreaks of diseases like Encephalitis in Bihar call for attention to reforms and the need for developing a resilient public health care system. We have a lot of costly lessons to learn from these events.

The case of the acute encephalitis syndrome

The experience in Bihar was not something new for the state. Each year, in the final summer months that preceded monsoon, many children below the age of 10 were usually affected by what was locally called the “Chamki Fever”. This Chamki fever is a serious neurological disease that results in high fever and affects the brain, leading to the its inflammation. Other symptoms included vomiting, stiffness of the neck, headache and confusion.

Technically known as the Acute Encephalitis Syndrome (AES), this disease has led to over 120 child deaths in the state of Bihar. The outbreak has been identified as viral although there are other agents such as bacteria and fungi that could cause it. Beyond this, it’s all speculation when it comes to identifying the causes. Virologists have remained puzzled regarding this disease, even though this has been an annual phenomenon for 3 decades. Some pediatricians have been able to narrow it down to 2 possibilities- the heat wave and litchi toxins.

The heat wave could in fact, be a potential explanation. The outbreak has, over the years, been intense in the month of June, right before the onset of the monsoons. The number of cases reported each year steadily increases in June and begins to fall with the onset of monsoon. At present, the epidemic has been contained which has been attributed to the onset of the monsoon. This association implies that there is something related to the change in temperature and the weather conditions of this time period that is making children vulnerable.

These speculations become clearer when we look into the social demographics of the affected population. Most of the affected children were malnourished and came from very poor families where the education level and incomes of parents were very limited. During the day, many of these children spent their time in litchi orchards, eating the fruit, occasionally unripe. Medical studies have been able to link litchi consumption and going to bed with an empty stomach with the onset of fever the following morning. The consumption of litchi, given that Muzaffarpur is a litchi cultivation region, could have something to do with the outbreak of AES.

The actual problem here can thus be deduced to a combination of causes that have interacted in a fatal manner; malnutrition, litchi consumption and the lack of basic medical facilities. The children who contracted AES, post the consumption of litchis were children who were already malnourished and went to bed without an evening meal. The biological process behind malnourishment it that even fats in the body start burning to produce energy, leaving behind residual materials that are neuro-toxic. Consumption of litchi would also leave behind by-products like MPCG that have the potential to trigger hypoglycemia.

These toxic substances released through the previously mentioned biological processes induce the state of hypoglycemia which leads to a sharp drop in the blood sugar level to almost zero. Children may experience convulsions and may even lose consciousness. The major drop in the blood sugar level is very fatal and is the cause for most fatalities. The treatment for hypoglycemia is however very simple, and requires the administration of glucose through the intravenous mode. The tragedy here is that most children affected are from the rural areas where the primary health centers do not have the basic facilities or the professionals to administer IV fluids.

The death of many young children and infants can be entirely prevented if they are immediately administered glucose but it is often too late when they are brought to the district hospital. The problem here has been intensified by the lack of basic health care facilities, the lack of which at the grassroot level is highly alarming. This requires an in-depth analysis of the structure and the stability of the Indian Public Health Care System.

Failure of the health care system in India

Health in India is a sphere which falls into the state list, and state governments as federal units are responsible for building and maintaining the health care system for their respective states. The central government engages in broader areas of health such as family welfare while the states are concerned with the running of hospitals. The public health care system operates at the primary, secondary and tertiary levels, beginning with primary health care centers to district level hospitals and medical colleges.

Given that the states are responsible for the health care system, in different states it is naturally not the same. Some states like Kerala have an efficient system while others lag far behind in terms of the health care system and health indicators. In the case of Bihar, the system has proved to be insufficient in dealing with an outbreak that has not been an unfamiliar one. This shows a huge failure in terms of the resilience of a system to adapt to the changing demands. The occurrence of the outbreak has been a common phenomenon and yet the system had remained unprepared for it.

The consequences this year have worsened manifold because of the fact that much of the preparatory activity has been neglected. Every year, awareness campaigns are conducted in the rural areas to educate parents about the perils associated with malnutrition, and the repercussions that litchi consumption has on malnourished children. Unfortunately, this year, the health department officials were engaged in the general election related duties, as a result of which, the awareness campaigns were not conducted extensively. However, the fact that the health system relies completely on the awareness campaigns to address an outbreak is questionable.

The very foundations of the health care system stand questioned because of the lack of basic facilities in primary health care centers. It also points to the lack of trained professionals to provide medical care at the grass root level and is alarming because India is a very populous country, and people cannot depend upon the medical facilities provided in major towns and cities alone. Government health care centers and hospitals in rural areas are often staffed by medical interns and other doctors who have been mandated to perform those roles but may not necessarily be interested in holding those positions.

Moving towards future solutions

It is tragic that events such as the AES outbreak in Bihar, occur quite often in India. With India being a populous nation, efficient and cost-effective health care is very important to meet the demands of a growing population. If we were to extend the right to life as mentioned in our Constitution, it would also include the right to affordable health care. A solution to this problem would involve a long-term approach wherein policy measures need to deliberately focus on building a strong health care system right from the lowest levels.

The Ayushman Bharat Scheme initiated by the Central government to extend a health insurance cover of up to Rs 5,00,000 to over 40% of the Indian population is a welcome measure in this direction. Positive and encouraging results have been derived with regard to the management of the Nipah outbreak in Kerala this year. The preparedness of the state health care system has enabled it to contain the spread of the disease and restrict the casualties.

Increasing the flow of funding towards primary health care centers and other units is essential to develop a sound infrastructure. Indian policy makers need to divert their attention and resources towards adopting a unified policy, learning from the success of some states and implementing them in other regions. The problem ahead is not impossible or unachievable; it just requires a long-term targeted strategy that would build a resilient and strong system.

Picture Courtesy- Down to Earth

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