Muzaffarpur Child Deaths: Bihar Needs to Make Health a Political Priority

Even five years after the state was struck by a similar tragedy, the ground realities that result in the disease have not changed.

Acute encephalitis syndrome (AES) has reportedly claimed 163 deaths in Bihar, according to latest reports. Many of them were children under seven years. The point to be noted is that AES and Japanese encephalitis have been the biggest killers of children in Bihar for quite some time. Yet, the state is looking for answers.

Epidemiologists who investigated earlier AES outbreaks in Muzaffarpur found undernutrition as a major underlying cause of death of children affected by the disease. While AES has struck other districts, Muzaffarpur is still the worst hit. A look at the profile of children affected by AES reveals that many of them are also from the most socially and economically disadvantaged families.

Diagnosis: the disease of poverty

This is a classic case of social epidemiology, a branch of epidemiology which has been neglected for too long in India, owing to our overemphasis on techno-centric solutions for health issues. By applying the social epidemiology lens, one can identify the social factors or characteristics that affect the pattern of a disease. Currently, discussions/debates have centred on the linkage between AES and the deaths of children. But we need to move from this theory of disease leading to deaths to a more nuanced understanding of how poverty affects some factors that end in deaths.

In 2015-16, as per National Family Health Survey, every second child under five years in Bihar was stunted or too short for their age, meaning that they have been chronically undernourished. This is one of the highest rate of chronic malnutrition globally. Interestingly, even ten years ago, the stunting was 56%.

This clearly puts the government in a tight spot as it did not succeed in making any major dent on undernutrition.

Across the world, malnourished children are prone to virus or bacterial infection due to immunodeficiency. The situation has been further compounded/aggravated by the physical environment in which the majority of the children live in Bihar.

According to the National Family Health Survey 2015-2016, more than two-third of the families in Bihar still do not have access to a toilet facility, implying that they are forced to go outside to ease themselves. In such situations, it is obvious that very few parents would have been practicing safe disposal of faeces passed by children under five years. Unsafe faeces disposal practices are associated with well-documented negative exposure to pathogens.

Worryingly, only 4% of households in Bihar have water piped into their dwelling, yard or plot. Only 5% of families treat their drinking water to make it potable. Thus, there are still a large number of families in Bihar, particularly those who are poor and residing in rural areas, who may be consuming water from unsafe sources. This exposes them to contaminated water, a well-identified carrier of AES.

Only 5% of families in Bihar treat their drinking water to make it potable. Photo: Pixabay

State’s response: Neither prevention nor cure

Bihar witnessed a tragedy in 2014, when hundreds of children died due to AES in the same region. Yet, five years later, the ground realities have hardly changed.

It would not be an exaggeration to argue that public health has not been a political priority in Bihar, despite the imminent threats of infectious disease epidemics.

The state has not only overlooked the key social determinants of the disease by not doing enough to check the unacceptably high level of undernutrition among children, it has also not undertaken significant public health actions (for example, AES spreads through contaminated water; hence, infection could be prevented by improving access to clean drinking water, sanitation and hygiene). Such actions could have brought down this periodic outbreak of infectious disease. Further, its health education programmes, such as awareness drives, seem to be too weak to have any major impact.

In 2014-15, on an average, the government spent only Rs 530 per capita on health. This was further reduced to Rs 491 in 2015-16 (the lowest in the country). In other words, the public expenditure on health on an individual in Bihar is just Rs 41 per month. Such abysmally low spending cannot be expected to deliver much.

According to the National Health Profile 2018, the average population served by a government allopathic doctor is 28,391 in Bihar, the highest across states. Not just the doctor to population ratio, even the government bed to population ratio is awfully low. The average population served per government hospital bed is 8,645, almost five times higher than the national average and ten times higher than Tamil Nadu.

In light of these facts, it is not surprising that children suffering from AES are not receiving the best medical care. The state simply does not have enough paediatric intensive care units in the affected districts.

The prognosis of the disease and the efficacy of the medical interventions can be judged from the following facts from the National Health Profile 2018.

Case Fatality Rate of Acute Encephalitis Syndrome, Bihar and India, 2013-2017

The above figure shows that the case fatality rate (CFR) of AES in Bihar has remained exceptionally high compared to the rest of India during the past five years. While the proportion of patients dying due to AES went down from 12% in 2013 to 8% in 2017 in India, their counterparts in Bihar were not as lucky. The probability of death continued to hover around 30% in the state. Such low survival rate in Bihar can be attributed to both poor prognosis and inadequate treatment. This implies that many of these premature deaths of children in Muzaffarpur could have been averted had they received timely and critical medical interventions.

Learning from this tragedy

The occurrence of periodic episodes of infectious disease outbreaks is not limited to Bihar. It may be recalled that two years ago, several low-income parents in Gorakhpur district in Uttar Pradesh had the misfortune to see the deaths of their children, linked to encephalitis.

To see that Muzaffapur and Gorakhpurs are not repeated, both the Centre and state governments need to make sustained efforts to eliminate the infectious disease from India. In Muzaffarpur, there is an urgent need to do deeper epidemiological research with a social perspective to understand the disease etiology, which in turn, would provide evidence based solutions. As the British epidemiologist Geoffrey Rose remarked:

“The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social.”

Soumitra Ghosh is assistant professor at the Centre for Health Policy, Planning and Management, Tata Institute of Social Sciences.