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Can a mysterious disease in Bihar open a window of opportunity for health care reform?

By Vikash R Keshri
on July 29, 2019

Bihar is the third largest state in India with a population of more than 110 million. It is also one of the most resource-constrained. The per capita income in the state is one of the lowest in the country. Vital health indicators of the state are also dismal, especially in comparison to southern states in India. Nevertheless, some of the indicators, particularly infant mortality rate, are very close to the national average. Another significant fact about Bihar is its very high total fertility rate and population density. As per the latest estimates, the total fertility rate was 3.2 and the population density 1106 per square kilometre. Unfortunately, the state also has a knack for being in the news in India more frequently for bad than good reasons. During this rather harsh summer season when the impact of heatwaves was/is being experienced not just in India but also across the world, Bihar was once again in the news with the death of >150 young children due to a so-called mysterious syndrome, locally known as ‘Chamki Bukhar’ (Convulsing Fever). The global media also covered this story.

Muzaffarpur is one of the largest districts in the northern part of Bihar, nearly 60 km away from the capital city of Patna. This district of 5 million people was “Ground Zero” of the ‘outbreak’ of this mysterious disease. Scientifically, the disease is called ‘Acute Encephalitis or Encephalopathy Syndrome’ (AES) and it mainly affects children under 12. Since 1995, this ‘outbreak’ occurs more or less annually, with a fluctuating number of cases and casualties. Earlier, this disease was considered to be ‘encephalitis’ due to infection by the Japanese Encephalitis (JE) virus, endemic in the area. Lately, the lack of conclusive evidence of infection and inability to isolate the JE virus from the majority of the affected children have directed attention to the possible non-infectious origin of the disease. Many possible hypotheses were proposed by researchers from the local treatment centres, research institutes from across India and also from a CDC (US) team. Some of these papers proposed the toxin present in ‘Lychee’ or ‘Litchi’, a white pulpy and sweet fruit which is abundantly grown in and around Muzaffarpur district, as the possible cause of the syndrome. It was claimed that a toxin known as ‘methyl cyclopropyl glycin’ (MCPG) can lead to toxic encephalopathy especially if lychee is consumed on an empty stomach. Heatstroke, especially among the hypoglycaemic children, was another plausible explanation proposed.  Many other hypotheses were also put forward but they were subsequently proven to be scientifically and clinically untenable.

In the months of May and June this year, the temperature spiked to 44OC. The number of cases also surged rapidly resulting in a very high number of child deaths within a short span of time. The high number of child deaths drew everyone’s attention towards this outbreak, both inside India and abroad. The media especially became extraordinarily active and started highlighting all the deficiencies and overall inadequacy of the health system, specifically the public health infrastructure. Politicians raised this issue in all fora including the parliament of India. Experts from all around the world offered possible solutions, trying to make a case for them. Poverty, hunger, malnutrition, lack of education and awareness, the absence of a mitigation and preparedness plan, and overall state capacity were the most frequently used words in these debates.  On one particular night, a primetime show on almost all leading national news channels on television was focusing on this issue. Fortunately, while I am writing this, monsoon has hit Bihar and the temperature level has gone down substantially due to frequent rain. Unsurprisingly, the attention paid to this story is also decreasing.

As reported by a leading national newspaper, a social audit conducted immediately after the outbreak found that the overwhelming majority of the children who died belonged to extremely poor households with severe scarcity of food and shelter. Another investigation by a group of doctors found that the doctors managing this case at the nodal hospital were not adequately trained to manage such cases. These two findings indicate two – in my opinion clear-cut – lessons from this tragic incidence. First, the importance of the basic social determinants of health such as poverty and livelihood, also in an ostensible ‘outbreak’, and secondly, proper mitigation and response to any such outbreak warrant the presence of resilient health systems. It’s obvious that Bihar has a long way to go on both counts.

The question is, then, can this tragic event open a ‘policy window’ for health sector reform in the state of Bihar and perhaps even trigger a discussion at the national level in India to revisit the health reform agenda? Applying John Kingdon’s (1984) multiple streams framework to analyse policy agenda-setting, we can examine this. The strong public and political sentiment about this sad incidence have definitely opened the ‘problem stream’, albeit temporarily. The interest of a plethora of experts from all over the world eager to contribute by examining, analysing and proposing solutions to this perennial problem seems to have opened the ‘policy stream’ too (ironically, in this part of India, policy actions are often guided by either the problem or politics stream whereas the impact of the policy stream tends to be very restricted). Last but not least, the outbreak has also temporarily hit the ‘politics stream’, although more in Bihar than at national level. Even if interest for the story is fast waning now, let’s hope the interplay between these streams leads to a robust agenda of health systems reform in the state of Bihar in the years to come, and perhaps also further improvement of the – still abysmal – social determinants of health in the state.

In addition, can this lesson also revive the discussion at the national level in India to revisit its strategy of healthcare reform towards the distant dream of achieving Universal Health Coverage (UHC)? For this, a robust Primary Health Care (PHC) led system is the need of the hour. Therefore, prioritizing the second pillar of “Modicare” (Health & Wellness Centres) is required more than anything else. But can India turn the tide and move towards PHC-led UHC?  Your guess is as good as mine. But let’s hope so.





Views are Completely Personal

(Vikash can be reached at vrkeshri@gmail.comTwitter handle:  @docVRK )


A well-arranged nutritional rehabilitation centre for malnourished children in Bihar