While travelling in Muzaffarpur, this correspondent witnessed the lack of basic health care services in the villages. The shortfall in primary health care centres (PHCs), doctors and paramedics, however, is not new. One PHC is supposed to serve a population of 30,000. In Muzaffarpur, 103 PHCs serve a population of five million people, whereas the requirement is 170. Local people complain that doctors are available for hardly one hour a day. Even the Shri Krishna Medical College Hospital (SKMCH) is short-staffed and lacks equipment. The condition of the other district hospital, Sadar Hospital, is no better.
At the Sadar Hospital, the chief paediatrician’s post is vacant. So are three posts of pharmacists and all seven posts of “dressers”. The hospital does not have a “sick newborn care unit” (SNCU) or a nutrition rehabilitation centre set up. A senior doctor at the hospital said: “Doctors can only treat and counsel. They cannot address malnutrition.”
The Medical Superintendent, Dr Mehdi Hasan, said most of the sick children arrived in a critical condition: “The poor sometimes cannot afford to feed the child in the night. Children go hungry. In the morning, if the parents are litchi pickers, the entire family goes along, and the children are likely to eat litchis. That is how the children get into a hypoglycaemic state.”
While Dr Hasan was talking to Frontline , a patient with a urinary problem came in and complained that his bladder would burst as he had consumed water on the advice of the ultrasonologist who was nowhere to be seen. “The bathroom is so filthy that I prefer passing urine in my clothes. Please tell me what to do. This is the fifth day that I have come, travelling 80 kilometres each day,” he complained. The doctor advised him to relieve himself and wait for the ultrasonologist.
Although the PHCs are understaffed, the new-fangled health and wellness centres, a brainchild of the NITI (National Institution for Transforming India) Aayog, have been set up. At one such centre, there is an “Ayush” doctor and an ANM (auxiliary nurse midwife).
NITI Aayog’s latest Health Index report that ranks States in terms of health outcomes listed Bihar among six least performing States which showed a decline in performance. Bihar registered the most negative incremental change, reflected in the deterioration of most health indicators such as total fertility rate, low birth weight, sex ratio at birth, institutional delivery, tuberculosis (TB) notification rate, TB treatment success rate, ANM and staff nurse vacancies, functional 24/7 PHCs, birth registration accreditation of facilities, CHC (community health centre) grading and fund transfer. Almost 60 per cent of ANM positions were vacant; over 50 per cent of posts at the staff nurse level were vacant at PHCs and CHCs. There was a 34.8 per cent shortfall of medical officers, and of the specialist positions 59.7 per cent were vacant. Only 53.79 per cent of PHCs were fully functional.
The PHCs tell a tale of apathy and neglect. The Kurhani PHC was recently upgraded to a CHC. It caters to a population of 5,36,000 people, roughly the population of two blocks. There was no ICU at the CHC, though a new AES ward had been set up in the wake of the outbreak. Against a total of seven sanctioned posts, there were only two medical officers on duty. The medical officer in charge, Dharmendra Kumar, said there were instructions to “refer” the cases to either the SKMCH or Sadar Hospital.
Dharmendra Kumar said: “How much pressure can a single doctor take? The doctor must join a video conference with the district magistrate, then come back to work, and come back at night again. A doctor works non-stop for 36 to 48 hours.”
The CHC lacked a paediatrician, a dresser and an OT operator. There was no X-ray or ultrasound machine. The additional PHCs did not have essential instruments such as glucometers. The CHC had been given an extra ambulance which, the MO said, would have to be “returned”. “The time factor is the biggest issue. If children are treated in time, they can be saved,” Dharmendra Kumar said.
A revised SOP (standard operating procedure) issued in 2018 for AES patients listed out the “Practical Aspect of Initial Management at PHC level”. The suggestions included putting the patient on an IV line, proper positioning of patient and suction, administration of Diazepam (0.3 mg/kg and not more than 1 mg/kg/min if there are convulsions), application of glucometer; and, for hypoglycaemia, the administration of 5 ml/kg of 10 per cent Dextrose IV bolus. There were instructions for the monitoring of danger signs and plans for referral.
Public health experts contacted by Frontline said that if a child is taken to a PHC and administered 10 per cent dextrose within four hours of the onset of the symptoms of hypoglycaemic encephalopathy, the disease can be controlled easily.
When the AES deaths came up in Parliament, Prime Minister Narendra Modi described them as a matter of “sorrow and shame” and suggested solutions such as immunisation, vaccination, safe motherhood and strengthening the Ayushman Bharat scheme. In the short poem “A worker’s speech to a doctor” by German Marxist playwright Bertolt Brecht, a worker tells his doctor: “Too much work and too little food make us weak and scrawny; your prescription says, put on more weight; you might as well tell a fish, go climb a tree…”
The solutions offered by Modi are not the kind of intervention required to address the sort of avoidable deaths of children that were witnessed in Muzaffarpur. A government that views disease from a purely medicine-based curative approach and not as a function of structural issues like livelihood and income levels is unlikely to succeed.
