Healthcare facilities in Bihar need urgent attention

According to National Vector Borne Diseases Control Programme, between 2008 and 2014 alone, epidemic of Acute Encephalitis Syndrome (AES) with unknown causes have led to 44,000 cases and 6,000 deaths across India, mainly in Uttar Pradesh and Bihar. At present, a single doctor attends over 17,000 patients in Bihar, state Health Minister Mangal Pandey had informed the Lok Sabha last year. In 2014, 375 children died due to AES and this year at least 130 have died so far. Despite this no attempt has been made to strengthen Primary Health Centers and Community Health Centers – the first rung in the state healthcare system.

Swati Subhedar and Chandrakant Mishra

On June 14, Rajesh Sahni's seven-year old daughter Roopa Saini started showing symptoms of Acute Encephalitis Syndrome (AES) at 5 in the morning. A resident of Haribanshpur village in Vaishali district in Bihar, he rushed her to a private hospital -- Kejriwal Hospital -- in Muzzaffarpur district, nearly 45 kms from his village.

The doctors here examined her for half an hour and then referred her to Sri Krishna Medical College and Hospital (SKMCH), nearly 10 kms away from this hospital. His daughter died the same evening. "She could have lived if only doctors at both the hospitals were more responsive," said Sahni, who was holding her daughter's photograph in his hands.

There are dozens of helpless parents like Sahni in Bihar who feel their children died because of doctor's negligence and poor facilities, especially at Primary Health Centers (PHCs) and Community Health Centers (CHCs).

This is not the first time an unexplained fever and administrative apathy has killed children in Bihar. This has been happening consistently year after year since past 25 years – since 1995. Every year annual occurrence of deaths has worsened with health system either not responding or responding too late to control the damage.

"More than 400 children died in 2001 due to suspected AES, around 375 died in 2014 and this year around 150 have died so far. If we know that this tsunami is going to hit us year after year, I fail to understand why are we never prepared," said Dr Arun Shah, a pediatrician, who practices at a private hospital in Muzaffarpur, Bihar.

Ground reality of PHCs and CHCs

Muzaffarpur district's Kanti, Mushahari and Minapur block were the worst affected and registered maximum number of AES-related deaths. Gaon Connection visited Minapur Public Health Center. Seven Additional Public Health Centers (APHCs) fall under this PHC – Panapur, Ghusaut, Sivaypatti, Turki, Gorigama and Majholia. There should be two doctors at each PHCs, but here three doctors were shuttling between these seven additional PHCs. They were working in shifts.

At the APHC in Turki, we met Mintu Kumari, 50, who works there as an Auxiliary nurse midwife (ANM). She said, "Two of us work here. One doctor and I. At this primary health center, there is no electricity and there are no washrooms. Every time we have to use the washroom, we have to go to someone's house. Since this PHC is half a kilometer away from the village, we have to walk that far every time we have to use the washroom. It's difficult to work like this."

After the outbreak, hospitals and PHCs suddenly saw a rush of patients. They were ill-equipped to deal with so many patients. Many volunteers took it upon themselves to spread awareness and help helpless patients. They too were shocked to see the condition of PHCs and CHCs.

"A child had high fever. I took her to the nearest PHC. I requested the nurse over there to measures her temperature. She hesitated. When we started pressurizing her, she confessed that there was no thermometer at that PHC," said Hrishikesh Kumar, who along with many others volunteered to spread awareness in Muzaffarpur.

On paper plan, but what about implementation?

After the recent visits of Bihar chief minister Nitish Kumar and Union Health Minister Dr Harsh Vardhan to SKMCH, the health department called upon PHCs and CHCs to lead the charge. "All PHCs and CHCs should have devoted AES wards, each with at least two beds. These wards with oxygen cylinders and glucometer, have to be airconditioned. They have been told that they must treat AES patients, not just refer them to bigger hospitals," Dr Harsh Vardhan had said in a press conference.

Despite this mandate, PHCs and CHCs, often short of both medical and non-medical staff, find themselves with their backs to the wall.

"We have a swanky new building. We have all equipment. But we don't have doctors to use this equipment. We need manpower. We have informed the authorities, but they do nothing to solve our issues," said Dr Ajay Kumar Pandey, who is in charge at Minapur Primary Health Center.

"We targeted Minapur, Kanti and Mushahari blocks in Muzaffarpur because they were the worst hit. People were completely clueless about this disease. They didn't know what preventive measures to take. We gave them glucose and biscuits," said Aditya Mohan, one of the volunteers.

All of them accepted that healthcare facilities in Bihar are in pathetic condition. "There are no facilities at most of the hospitals. Doctors don't arrive on time and even basic medicines like paracetamols are not available. On top of that health workers behave very rudely with people," said Somu Anand another volunteer.

People opted for private, government hospitals over PHCs

"I took my son Lakhshvir, 3, to the nearest Primary health Centre soon after he fell sick. There were 4 children on each bed. There were no oxygen cylinders, there were no doctors. When the doctor arrived, he said he won't be able to help us much as there were no additional doctors," said Chhindan Singh, 36, who lives in Gaygir village in Muzaffarpur.

"I couldn't see my son in pain. So, I took him to IT Memorial Hospital. He was there for 36 hours, but they didn't admit him and referred him to another hospital. And from there we were sent to another hospital and then finally to SKMCH. So much time was wasted and I have spent Rs 3 lakh so far," added Singh, who runs a grocery shop.

There were many parents who took their children to nearest PHCs first from where they were referred to bigger hospitals and there were many who didn't bother going to PHC as they knew their children won't get quality treatment there and they didn't want to waste crucial initial few hours.

Like Raj Kumar Manjhi, who took his son Shiba Kumar, 7, straight to Kejriwal Hospital in Muzaffarpur. "I didn't want to waste those crucial hours. Instead of taking him to a PHC, that would have referred him to a big hospital anyway, I took him to a private hospital," said Manjhi.

As on March 31, 2017, there were 25,650 Primary Health Centers (PHCs) functioning in India, according to government data. The top 5 states/UTs in terms of maximum number of PHCs functioning were Uttar Pradesh, Karnataka, Rajasthan, Bihar and Maharashtra. There were 1,899 PHCs functioning in Bihar as on March 31, 2017, which accounted 7.4% of the total PHCs functioning in India.

UP Chaudhury, medical officer at Kanti Primary Health Center in Muzaffarpur, said: "We have all the facilities at our PHC. Some 22 children came to our PHC. We sent them to the hospital at our headquarters in Muzaffarpur (SKMCH) only after giving them primary treatment. But yes, despite all the facilities, we were not confident enough to treat children."

"There are doctors at PHCs. They mostly work in shifts. These doctors are not available during daytime, forget them being available at night. I visit so many villages, and I never find doctors there," said Dr Shah.

What is ailing the healthcare system in Bihar?

Chaturi Saini, 28, feels he is the most unfortunate father in this world. He lost his two children in the span of 24 hours. He lives in Haribanshpur village in Vaishali district, 60 kms from Patna in Bihar. It's the same village where 16 children are said to have died due to AES.

"I had just reached home in an ambulance which was carrying dead body of my elder son, who was 7. We were making arrangements to bury him. Just then health of my younger one, who was 1.5-year old, deteriorated. We rushed him to a hospital, but he could not survive," said Chaturi while sobbing.

Chaturi first took his child to a private hospital in Lalpur. He was asked to take his ill child to Sadar hospital in Hajipur, a headquarters in Vaishali district. From here he was sent to Patna Medical Collage and Hospital (PMCH), which is 25 kms away from where he was. Chaturi didn't have enough cash so he came back home.

"We somehow collected some cash and took him to Muzaffarpur's Kejriwal hospital. The doctors refused to admit him and instead sent us to Medical college in Muzaffarpur, where he passed away at 3 in the morning," said Sushil Saini, Chaturi's brother.

Chaturi's wife Chanchal Devi and 1.5-year-old son was with them. When the family was coming back in an ambulance which was carrying the dead body of his elder son, his younger one fell sick and started showing symptoms of AES.

"We didn't even bury our first-born. We rushed the younger one to a hospital in Lalpur, but everything was shut there. We then took him to Sadar Hospital. The doctor there didn't even touch my child and asked us to take him to Patna Medical College and Hospital. We didn't get any help there. At 12, my son passed away," said Chaturi.

He added: "The doctor over there asked us to take him back home. We asked for an ambulance. There were none. I had to spend Rs 2,200 from my own pocket to bring my son's dead body home. My son didn't get proper medication. He could have survived."

There are many Chaturis in Bihar. They are furious. They are blaming the government, negligent doctors at hospitals and health centres and ill-equipped medical staff, who they say are not prepared to deal with a tragedy of this magnitude.

Dismal track record

A NITI Aayog report released recently mentioned Kerala took the top spot among larger states for overall performance on health indicators, while Uttar Pradesh, Bihar, and Odisha languish at the bottom.

Bihar has a significantly high vacancy rates for doctors in the public health system resulting in total dependence on medical colleges or district hospitals, which turn out to be congested, the report said. Last year, during the Assembly session, state health minister Mangal Pandey had said at present, a single doctor attends over 17,000 patients in Bihar.

"We walked 70 kms to this hospital in Muzaffarpur, but out miseries have not ended. The washrooms are so dirty that I go out in the open," said Mahesh Kumar, relative of a patient who was admitted in SKMCH.

Many parents who children died due to AES in Muzaffarpur felt their children could have survived if doctors were more responsive and hospitals more prepared.

Nine-year-old Simani is admitted at the Medical College. She didn't get any bed. She was lying on the floor. Simani's younger sister had succumbed to AES just a week back. The ambulance that carried her body home, also carried Simani back to the hospital because her health had deteriorated while the younger one was battling for her life. Now, Simani too is slipping away. Her mother is in a state of shock.

On June 6, addressing the media after holding a review meeting with senior health officials, health minister Dr Harsh Vardhan had set timelines for completion of different tasks to combat AES.

He proposed setting up a state-of-the-art, multi-disciplinary research unit in Muzaffarpur, besides a composite, full-fledged paediatric intensive care unit (PICU), having at least 100 beds at SKMCH. "There is a need of a state-of-the-art research centre to tackle this challenge in Muzaffarpur which will work in collaboration with the ICMR and the WHO," he had said.

This was said in a speech. What about implementation?

Like Kailash Kumar, a relative of a patient, said: "My son is admitted here (SHMCH) since past two weeks. There is no drinking water here. Every time someone comes to visit him, I have to buy water. I have spent Rs 1,400 on drinking water so far. If I had to spend so much, I would have treated my son at a private hospital."

This will continue to happen till the state takes some serious steps to improve heath facilities at PHCs and CHCs.