The death of hundreds of children in the eastern state of Bihar has sparked off a furious political slugfest while raising disturbing questions about India’s broken health care system.

As of the morning of June 20, 128 children are recorded as having died of Acute Encephalitis Syndrome in Bihar’s Muzaffarpur district, at Sri Krishna Medical College and Hospital and Kejriwal Hospital. Since January, around 1400 children from Muzaffarpur and adjacent districts have been admitted with AES to the two hospitals.

The death toll skyrocketed this month, causing people to ask why the system hadn’t been fixed following major outbreaks five and seven years earlier.

AES is characterized by an onset of brain fever and clinical neurological manifestation that includes mental confusion, disorientation, delirium or coma. Extremely young children who are severely malnourished are most prone to the virus. Experts point out that by the time the children are admitted to the hospital, doctors have only a few hours to save them. Extreme poverty and the lack of decent primary health care facilities in the villages are major factors behind hundreds of deaths every year.

Infant deaths in India are the highest in the world, according to United Nations agencies UNICEF and the World Health Organization as well as the World Bank. Lack of access to water, sanitation, proper nutrition and basic health services resulted in 802,000 infant deaths in India in 2017 alone, according to a report by the UN Inter-agency Group for Child Mortality Estimation.

Although the Bihar government and medical authorities have cited multiple causes for the outbreak, the incident  has largely exposed the state government’s lack of preparedness. The state is currently ruled by an alliance between the Bharatiya Janata Party and Janata Dal United. The rising death toll has embarrassed the federal government as it is run by the BJP.

Chief Minister Nitish Kumar announced a gift of 400,000 rupees each to families of the deceased and gave directions to the Health Department, district administration and doctors to take necessary measures. But that was not enough to placate people who have been at the receiving end of an ill-equipped healthcare system for years.

The chief minister faced huge protests on Tuesday with people shouting, “Go back Nitish Kumar” as he arrived at Sri Krishna to take stock of the situation. Later, activists gathered in front of Bihar Bhawan, the office of the state’s commissioner in Delhi, and protested the deaths, seeking the resignation of Kumar.

Union Health Minister Harsh Vardhan also had faced protests when he arrived on Sunday. As Sri Krishna’s hospital lacks a pediatric intensive care unit, Vardhan announced that the medical college will get a 100-bed pediatric ICU in a separate adjacent building in a year. He had made similar promises in 2014, during an outbreak, to set up dedicated beds for encephalitis patients and build a virology center. But nothing had happened on the ground.

Lack of resources

“More than the disease, the system’s failure is causing the deaths of children,” said Dr Kafeel Khan, a former encephalitis specialist at the BRD Medical College in Uttar Pradesh. He is in Muzaffarpur with his team for the past two days to help mitigate the crisis.

AES is not new in India or the state. The disease is endemic in 22 States, of which Assam, Bihar, Tamil Nadu, Uttar Pradesh and West Bengal have been reporting more than 80% of the cases. It generally strikes as summer peaks and before the monsoon arrives.

Bihar, particularly Muzaffarpur district, has been reporting high numbers of cases of acute encephalitis among children since 1995. It saw a severe outbreak in 2012 – when 178 children reportedly died. In 2014, there were around 90 deaths. Even after that, no infrastructural overhaul or holistic policy change seems to have been made to address the decades-old problem.

There is a dearth of doctors, medicines and the necessary equipment to treat patients amid the crisis. To make matters worse, there have been reports of power cuts in hospitals in Muzaffarpur which have no backup generators.

“Over 300 patients of AES have been put in a hall” at Sri Krishna “with only fans and no air conditioning, which will make their conditions worse in the hot and humid weather,” said Dr Khan, who visited the hospital on Tuesday.

The standard ratio should be one doctor per four patients as prescribed for critically ill children by the WHO. But at Sri Krishna “over 200 children are being attended by only four doctors and around five assistants,” said Dr Khan. Sick children are also made to share beds or sleep on the floor due to lack of space in the hospital.

Dr Vishal Upadhyay, a senior orthopedic surgeon, is the founder of the Medijunction e-clinics, which have three centers providing tele-medicine services in Muzaffarpur. “It’s not just the hospital’s fault,” he told Asia Times. “There is a lack of qualified doctors in under-developed, rural areas due to lack of incentive. The Muzaffarpur area is impoverished” and people cannot afford private healthcare. “With a long history of such outbreaks,” he added, “the onus was on the government to create better medical facilities in such a place.”

Dr Upadhyay said his clinics in Muzaffarpur have been diagnosing AES-affected people and sending them to government hospitals. People working in the clinics claimed that the official death toll figures are heavily skewed as many children from poor families die without being diagnosed or having proper treatment, he said. Additionally, Dr Khan claimed that the deaths of patients admitted in private hospitals are not being counted in the official figures.

The National Human Rights Commission has asked the Bihar government for a detailed report. It pointed out that the high death toll of children indicated that there was a “possible flaw” in the proper implementation of the vaccination and awareness programs.

Contested narrative

The state government earlier did not cite AES as the cause and instead attributed most of the deaths to hypoglycemia (low blood sugar levels). Experts, however, say hypoglycemia is one aspect of AES, which is an umbrella term for all symptoms which cause inflammatory brain diseases. They could be caused by bacteria or virus and are difficult to identify individually. In India, the most common pathogen for encephalitis is the Japanese Encephalitis  virus.

A team that was formed by the state to ascertain the cause of this disease concluded that sleeping on an empty stomach at night, dehydration due to humidity and eating lychee on an empty stomach were some of the causes of encephalitis. Doctors have also claimed that these deaths are being caused due to excessive heat and humidity.

“These are all assumptions,: Dr Khan said. “We don’t know the enemy we are fighting against and there is no available treatment for AES. Doctors treat whatever symptoms arise,such as fever.”

Dr. Upadhyay added, “If a child is infected with a virus, the disease has to be caught early to avoid high mortality. But due to lack of primary healthcare units and sub-centers, the children are often taken to some local quack doctor first or taken too late to the hospital.”

The Bihar government has ordered a socio-economic survey of the families in which children became sick to determine the cause of the disease.