Despite the visibly painful effects of Japanese encephalitis and acute encephalitis syndrome, political parties have not thought of it as an important political issue.
Gorakhpur, Uttar Pradesh: As the elections in Uttar Pradesh wind down, one thing is clear: most political parties have ignored one of the more crucial problems assailing the state. A dying public healthcare system has gone completely unnoticed in a high-pitched battle between parties focused on striking the right social coalition.
A dismal state of affairs prevails in many villages in UP: primary healthcare centres are either not present or lack basic infrastructure to address the most common sicknesses. Exacerbating this problem is a paucity in the number of paramedical staff – leave alone doctors – all together keeping UP in a state of almost perpetual distress.
The sole exception might in fact be Chief Minister Akhilesh Yadav, who has been speaking about the state-funded ambulance service that has worked well on ground. At the same time, many health experts agree that while the ambulance is an important relief measure, schemes like it don’t address the larger problem of public healthcare in UP. They also think it is a sop when in its place should be efforts to revamp the public infrastructure.
A big case in point: the climbing incidence of Japanese encephalitis (JE) and acute encephalitis syndrome (AES) – viral infections that affect the brain and lead to coma, death or serious disabilities – in eastern UP. Every year, in Gorakhpur alone, more than a thousand die of JE and AES between July and December. According to official figures, around 25,000 children have succumbed to JE and AES since 1978.
Doctors in this part of the state say that these are only the recorded deaths in Gorakhpur Medical College, which in turn is the only hospital in a 300 sq. km patch of land to have decent facilities to treat these diseases. The diseases are carried by two species of mosquitoes: Culex vishnui and Culex tritaeniorhynchus.
Right from Basti, Gonda and lower Nepal to districts bordering Bihar, the incidence of JE and AES among children younger than eight are unnaturally high. Experts believe that these acute infections become more prevalent during the monsoons and the months following right after. The Culex varieties of mosquitoes breed in the dense water-logged paddy fields of the region and spread from the villages to urban centres nearby.
“Many children of the area get this peculiar variety of fever. If not treated properly, they either die or lose mental stability,” Mohammed Asfaque of Manbella village, Gorakhpur, told The Wire. Asfaque himself has lost two of his daughters to JE.
Several people across Purvanchal, the section of eastern UP where Bhojpuri is the dominant tongue, complained about inadequate treatment facilities in the area. The incidence of JE hovers in the 6-8% range while far more cases are diagnosed as AES.
However, an important concern here is that nobody knows what causes these annual outbreaks – or the precise mechanism of action through which AES itself affects the body. The name ‘AES’ is only a convenient placeholder for a cluster of symptoms whose causes will someday, hopefully, come into better focus and which the government will be in a better position to address.
As Priyanka Pulla wrote in the September 2016 issue of Fountain Ink,
According to WHO, a patient suffering from fever, altered mental status with or without seizures should first be tested for Japanese encephalitis. If the results are negative, it would be an AES case and tested for similar illnesses such as bacterial meningitis and herpes simplex encephalitis. In essence, AES was defined as any illness that looked like Japanese encephalitis but couldn’t be confirmed as such.
Kafeel Khan, a doctor in charge of the encephalitis ward in Gorakhpur medical college, told The Wire that though the government had been importing JE vaccines from China, JE levels have not fallen by 4-5% while the incidence of AES “remains high”.
There are no proven methods to prevent the viral infection, so the treatment has to be immediate. If a child is not brought to an ICU within 24-48 hours of having been infected, she is most likely to die or develop a permanent disability.
The fever is generally accompanied by seizures, after which the child goes into a coma for three or four days. If treated on time, she could recover but then the risk of developing a permanent physical, mental or neurological disorder will persist.
“The vaccinations have helped but not much because of poor awareness levels in the area. The mortality rate is anywhere between 25-40%. Almost 15% of children who survive develop some sort of disability,” said Khan.
There are only 66 Encephalitis Treatment Centres (ETC) for the 20 million people of Purvanchal, and they are inadequately staffed and poorly managed. As a result, people often turn to under-trained quacks incapable of effectively handling what are the more complicated cases of JE and AES – especially when they cannot afford expensive private healthcare. Several villagers told The Wire that they take their children to uncertified local practitioners. Evidently, doctors and paramedical staff have not been appointed in sufficient numbers in the last few decades in UP.
Given this, much of the responsibility to treat JE and AES falls on the Gorakhpur Medical College. And “it is impossible to bear the load that we have here. Because the mortality rate is so high in this, every doctor refers the patients to the medical college,” Khan said.
He added that, at any time, the college can support 300 patients at most. But during the monsoons and the months that follow, the college handles more than 1,000 patients at once. Between 60 and 70 cases are admitted every day during this period. “We have 300 beds. The state government provided 56 beds and a separate centre to us a few years ago. The central government in 2012 also gave us another 100 beds.” As a result: “During the monsoons, we have to accommodate three children in one bed.”
The nurse-to-patient ratio in the medical college – 1-to-6 – is also terrible. On top of this, the treatment of AES and JE is only symptomatic as doctors rely on antibiotics to prevent the infections from worsening; this form of treatment has only been partially successful.
After a much-reported crisis in 2012, the Centre issued guidelines for treating JE and AES more effectively. But in these parts of the country – where they are most relevant – they are hardly followed because of the prevalence of untrained private practitioners.
Since 2008, 4,842 children have died of JE And AES in Gorakhpur Medical College alone, and the rate of deaths has not been slowing. Then again, this is not the real figure according to Khan because most cases in Purvanchal go unreported. “This is just the tip of the iceberg. My reading is that almost 99% of deaths happen without any treatment and, thus, go unreported. The figure we give is just the cases we got,” he said.
According to medical experts, successive governments have missed the actual point by concentrating almost exclusively on treatment. “The government should focus on prevention,” said Manoj Singh, a senior journalist in Gorakhpur who has been covering the JE/AES outbreaks for many years. “It should ensure proper drinking water supply and sanitation in villages so that the disease does not spread.”
Singh added that primary health centres (PHCs) and district health centres (DHC) in villages should be properly equipped with adequate staff and infrastructure to stem the problem at the village-level itself. He agreed that only one institution – even if it was as big as a medical college – will not be able to address the problem. As a measure of immediate relief, many say, the quacks could also be trained.
Khan said that if the first stage of treatment is given on time at the village level, the mortality rate would come down drastically. He also said that vaccination programmes should also be given a boost.
Hundreds have died or have been left disabled because of the spread of this deadly fever in Purvanchal. Despite its effects – on individual lives as well as entire families – political parties have not thought of it as an important political issue. Elections aside, the bigger question is how many children will they let die before the political class thinks of the public healthcare machinery as a developmental issue.