In Retrospect

The Bihar Debacle

Bihar's Acute Encephalitis Syndrome (AES) crisis is neither natural nor unbelievable – it is only reflective of a larger disease that plagues India's healthcare facilities, particularly for the poor

154 children have now succumbed to Bihar's staggering healthcare disaster. Though entirely man-made, man's preparedness to counter this disaster remained abysmally absent. Acute Encephalitis Syndrome (AES) has been typical to Bihar, eastern Uttar Pradesh, Assam, Odisha and West Bengal. AES is an umbrella term for infections that cause distortions in the brain with symptoms including loss of consciousness, headache, vomiting and seizures, ultimately leading to memory loss, coma and even death.

Undoubtedly, the disease is potentially fatal – yet, Bihar government's ability to counter this very known evil in its own backyard has been shamefully inadequate. This isn't the first time that Bihar has been gripped with an epidemic of this scale. 'Chamki fever', as the disease is locally known, first appeared in Muzaffarpur in 1994. In 2012, the state witnessed the death of 120 children, while in 2014, it was 355. AES is most dreaded in these parts of the country that are already writhing under years of poverty, malnourishment and steep medical expense. The basic hinderance in battling AES has been the difficulty in recognising its exact cause. While Japanese Encephalitis (JE) is a virus transmitted through mosquitos (mostly), AES could occur either through water contamination or due to hypoglycaemia i.e., a decline in sugar levels (less than 70 mg/dL). In Muzaffarpur – a district marked by poverty, affected annually by debilitating heat waves and known for its luscious litchi orchards – children who lack adequate nourishment become easy preys.


Muzaffarpur houses 103 primary health clinics (PHCs), of which 98 were insufficiently equipped, while the entire district has only one community health centre (CHC). These numbers are frightening and well below the requirement which states that there must be one PHC for every 30,000 people and one CHC for 1.2 lakh. Going by this, Muzaffarpur should ideally have 170 PHCs and 43 CHCs. Worse, the entire state of Bihar houses only 70 CHCs for its population of close to 11 crore. That the disaster is man-made and reflective of utter administrative failure is now, unignorable.

After the 2014 epidemic, Bihar government had adopted Standard Operating Procedures (SOPs) in consultation with UNICEF to check upon the spread of AES by undertaking community awareness programs ahead of the onset of monsoon, the most typical time for AES. The programme did well in its first four years with the death toll coming within control. But in 2019, the SOP was grossly ignored.

"This is a disaster and total failure of the Bihar government. Bihar has been suffering from AES for the last two decades at regular intervals and yet, the government has failed to prevent its spread and fatality. Standard Operating Procedures were shelved and for that negligence, we are today grappling with the death of over 150 children," said Dr Shakeel-ur-Rahman, General Secretary, IDPD and Convenor, Jan Swasth Abhiyan, Bihar.

"Of the 11,000 posts for doctors in Bihar, only 2,500 have been filled, leading to a 70 per cent deficit and thereby, 70 per cent absence of proper treatment. Unless these loopholes are filled soon, there will be no remedy when such a crisis falls upon us," he added. Indeed, while WHO recommends one doctor for every 1,000 patients – India, on an average, has one doctor for 11,082 patients. Bihar, again, is the worst off, with one doctor available for 28,391 patients.

While inadequate medical structure is at the epitome of Bihar's crisis as well as India's overall crippling healthcare, poverty as a social detriment cannot be ignored. Malnourishment continues to be a great threat to our country. While reports suggest an overall improvement in stunting, acute malnutrition has only grown over the years. Bihar, Uttar Pradesh, Jharkhand and Meghalaya are the worst-affected with children suffering from major deficiencies of Vitamin A, Iron and Iodine.

Hypoglycaemic Encephalopathy, in news this time, has resulted from a combination of malnourishment and intake of Hypoglycin A, abundantly available in the many litchi orchards of Muzaffarpur. Children in these impoverished areas often sleep without a meal and wake up to experience sharply reduced sugar levels coupled with deadly symptoms of AES. Poverty and unchecked consumption of litchi have combined to present a disaster. And, Bihar has stood grossly unequipped.


A simple method to contain AES, which has been administered before, has been the injection of dextrose into the bloodstream. A simple sugar, 10 per cent dextrose dose is sufficient to contain AES, which was elicited earlier in 2014 when health officials were able to save 74 per cent of those suffering by injecting dextrose right at the onset of the disease. In 2015, local health officials also began spreading public awareness about the harms of sleeping on an empty stomach — this sharply reduced cases of fatality. This time too, with timely dextrose dose administration in the ambulance, the disaster could've been controlled. Yet, Bihar failed both in prevention by awareness and cure with timely doses of glucose.

"We must begin treating this entire health machinery – health concerns, institution, doctors, etc., – as a churning disaster. The loopholes are too many and we cannot wait for a crisis to strike. Just as we prepare for floods, we must prepare for AES in Bihar. We have to ensure that food is

available through the year and the SOP must be followed meticulously," Dr Rahman added.

The share of health expenditure in India's GDP continues to be among the worst in the globe at Rs 1,112 per capita. Even Sri Lanka spends four times more than us and Indonesia twice as much. Public hospitals are ill-kept, lack basic facilities and suffer from a gross deficiency of doctors. To make things worse, we never learn from our mistakes.

Uttar Pradesh's Gorakhpur, once the hotbed of Japanese Encephalitis (JE), has done well in curbing the crisis with its Dastak campaign that led with the bold slogan of 'Darwaza khatkhatao, AES aur JE ko bhagao' (Knock from door-to-door to chase JE and AES away). With support from UNICEF, the campaign travelled across 38 vulnerable districts to apprise people in prevention methods – and, since then, Gorakhpur has been less known for this deadly disease.

Bihar ought to step up now and India, at large, must at least be cognizant of its innate health crisis. Medical tourism is doing well in our country, with foreigners making their way into our very plush private hospitals and contributing vigorously to foreign exchange. Yet, our own home remains grossly diseased and uncared for. Children are malnourished, women suffer from anaemia and men remain vulnerable to variations of tuberculosis. We are an ambitious country, raging to grab our deserved place in global politics. Yet, our home stands in penury.

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