MUZAFFARPUR, Bihar — The Acute Encephalitis Syndrome (AES) death toll in Bihar is 154 — and still rising.
Hundreds of children have died of AES, and given the state of Bihar’s health sector, children will continue dying from this deadly brain inflammation.
In a conversation with HuffPost India, Ranjit Kumar, a Patna-based government doctor, who is General Secretary of the Bihar Health Services Association, said that AES will kill until Bihar gets doctors, medical infrastructure, and finds a way to combat poverty.
But the biggest problem, Kumar believes, is that bureaucrats are in-charge of all decision making when it comes to the health sector, while doctors are completely sidelined.
Kumar, who is also General Secretary of the All India Federation of Government Doctors Association, said, “If the government does not keep doctors who live here in the decision-making process, then this situation will arise.
Why is Bihar not prepared to tackle an AES outbreak?
When it comes to making policies in a technical field, when bureaucrats dominate, when bureaucrats take all decisions, and the role of doctors — at the local level and at the upper level — is ignored, this kind of crisis is bound to happen.
In Bihar, bureaucrats make all the decisions, doctors are completely removed from the process. Politicians come and go, move from one department to another. If the government does not keep doctors who live here in the decision-making process, then this situation will arise.
How do you mean?
Take for instance the promise to set up an institute for AES research in Muzaffarpur. The promise to set up a 100 bedded paediatrics unit, four years ago. These were never considered a priority. The biggest problem is setting priorities. Doctors have no say in this decision making process and yet we are the ones who are questioned. The house surgeon is getting grilled about the number of beds, but does he even have the status of increasing one bed?
“When bureaucrats take all decisions, and the role of doctors is ignored, then this situation will arise.”
What is wrong with Bihar’s health system?
The lack of human resources. There are no paramedics. Even the paramedics who are there, have they been trained to handle this (AES). You will find doctors in Patna and the district hospitals, but not in the periphery. Even in Patna, there will be one doctor for a population of 50,000. So can you imagine the state in the periphery?
How many doctors are there in Bihar?
There are 2,220 doctors in Bihar.
How many should there be?
There are 11,373 sanctioned posts in health services. And there are 2,500 doctors, but these include civil surgeons, DIOs (District Medical Officer), CMOs (Chief Medical Officer). There are around 500 posts that are not connected directly to health services but to administration.
There are 1,500 doctors that are graduating in Bihar, every year, and yet there is a shortage of doctors in the state. What is the reason for this? Why do we have a faulty recruitment policy? After 2016, we are still waiting for an advertisement.
In medical colleges?
There are 65% vacant posts in medical colleges. There are 60% vacant posts for professors and 70% vacant posts for associate professors.
In Tamil Nadu, 95.6% of positions in the teaching cadre are filled. In Bihar it is 35%. We need to strengthen the medical college. We need to increase its seats.
How many doctors are there at Shri Krishna Medical College and Hospital (SKMCH) in Muzaffarpur?
From what I know, there are 15 to 16 doctors (paediatricians) at Muzaffarpur including the head. There is a professor, three associate professors, five assistant professors and six or seven junior residents. Now, you want an associate professor to stay in each of the four wards (Paediatric Intensive Care Units), but you only have three of them. How can they monitor these wards 24-7? How can these 15 or 16 persons monitor these wards?
They have to look at Emergency, the four paediatric wards, teaching, and if you are head of department then organisational matters. They are not just looking at AES patients. They have to look at everyone. How is that sufficient?
(SKMCH is handling the bulk of the AES cases from Muzaffarpur, the epicentre of the crisis.)
How does the system cope with the lack of doctors?
First, we used to retire at 60. Now, it is 67 years of age. Then, it will be 70 and then 90. In Madhya Pradesh, doctors over the age of 50 do not work in Emergency.
In Bihar, 50% of the posts have doctors over the age of 50 or 60. We need a new generation of doctors. We need to recruit doctors.
What about workload on doctors?
There are some places where a Primary Healthcare Centre (PHC) is being handled by one doctor. There are other places where a PHC is being handled by two doctors. There is organisational work, payments to ASHA workers. How much time is left for treatment? There is no time to treat patients properly.
One doctor is faced with a crowd of 200 people coming in - what treatment will that doctor do? The doctor is sitting in the middle of the crowd, distributing something, something. Sometimes, the doctors end up feeling like the culprits.
“Doctors are so few that they are quite literally panting. Sometimes, the doctors end up feeling like the culprits.”
What about safety?
Doctors are so few that they are quite literally panting. Paramedics are so few that they are panting. They are all panting and scared. Sometimes, we say that if god exists then it is in Bihar. If a crowd comes in and the doctor survives then it is thanks to god.
What is the workload like for the ASHA (Accredited Social Health Activist) healthcare workers?
The ASHA worker has taken healthcare to the general population. ASHA is a huge weapon in our hands. There are large-scale vaccination programs underway. But with the series of health programs under the NHRM (National Rural Health Mission), the ASHA workers, the ANMs (Auxiliary Nurse Midwife), the doctors, are all very tired.
Even in the pulse polio vaccination program that is going on, we are getting news of healthcare workers falling sick. They have to cover 100 houses, but they are falling sick after 60 houses. They are getting fever and complaining of pain in the abdomen. Then, we are hearing of cases in which their kin are having to finish vaccinations in the rest of the houses.
“The ASHA workers, the ANMs (Auxiliary Nurse Midwife), the doctors, are all very tired.”
What is lacking in infrastructure?
The infrastructure is poor. This isn’t just under the Nitish Kumar government, but it’s always been like this. In all the Five Year Plans, it was said that the infrastructure would be developed, but what had to happen, never happened. Four years ago, the Union Health Minister (Harsh Vardhan) had said that a 100 bedded paediatric unit would be made at the SKMCH. That did not happen.
What is needed?
For a long time, we have been demanding the strengthening of infrastructure. We have been demanding that beds in the Emergency and Intensive Care Units (ICUs) of existing hospitals needs to be increased, and not just in Muzaffarpur and Patna. Darbhanga is another zone, Gaya is another zone, Bhagalpur is another zone. We have been demanding that increase the number of ventilators in the ICUs. But no one listens to what we (doctors) say.
Are these hunger deaths?
There is malnutrition. There is no safe drinking water and sanitation. It’s not that the government has done nothing. It has set up anganwadi centres, the midday meal scheme. But the specification that is needed, is not there. The implementation that is needed, is not there. Just giving money is not enough. How will the scheme be implemented and what will be distributed? If you are distributing, for instance, iron tablets to combat anaemia, but if there is no health education, then those tablets are going to end up in the gutter.
“Just giving money is not enough. How will the scheme be implemented and what will be distributed?”
If there is no health education, then people will continue taking their children to quacks before getting to the hospital. This wastes precious time. Due to lack of health education, people will only move to hospitals when children are in a very serious condition. It is usually when the convulsions set in.
There have been so many deaths, but we still don’t know what actually causes AES?
The kind of research program that was needed at the national level — that was never done. A research institute was supposed to be established in Muzaffarpur, but it did not happen. We still don’t know the reasons (for AES).
Malnutrition is at the heart of it?
Poverty, poverty, poverty. What will awareness do in the face of so much poverty. There is no drinking water. If the ASHA workers are going and saying, ‘drink clean water,’ people are saying ‘where is the water’?
“What will awareness do in the face of so much poverty. There is no drinking water.”
What steps were taken after the AES outbreak?
Pamphlets were distributed. There is massive distribution of ORS (Oral Rehydration Solution), which will cover half the population in the state. But the question is why not before?
When the infrastructure is debilitated, there are no human resources, when there is no proper policy in place — this was an AES outbreak — but there could be other things that we are not prepared for. There could be floods in the monsoon. Then, there will be a huge problem of diarrhoea.
What needs to be done to prevent such a crisis in the future.
A special program for children to get highly nutritious food should be in place. There should be health education, and not just for AES.
The ICU facilities in all the district hospitals should be improved. It isn’t enough to say that Muzaffarpur will get another 100 beds. The government has to strengthen all the district hospitals. For this, you need trained staff. You need doctors that correspond to the population.
“But the question is why not before?”