From the lens of a development journalist
It was the height of summer in Bihar and Uttar Pradesh (UP) in 2014 and cases of Japanese Encephalitis for Encephalitis Syndrome (AES) were on the rise. Thirty one districts of Bihar and 39 of UP are JE endemic, and vaccination campaigns were being launched in a systematic manner to ensure that all children of 1 to 15 years got protected from JE and there is early diagnosis and treatment of AES which has the same symptoms as JE—fever, mental imbalance, convulsions and coma.
The difference between the two is difficult for most people including journalists to understand. However, what was heartening was the general acceptance of the JE vaccine as a good preventive to save lives of children. In fact, studies conducted in Nepal and China, also JE endemic, have shown that the SA 14-14-2 JE vaccine, also being used in India, has 99 percent efficacy after administration of a single dose. However, it is not a preventive for AES, which for the common man seems the same. A clean environment and clean drinking water are basic for all health programmes and this is something that has to be understood and acted on by civic authorities working closely with health authorities. The fact that medical authorities and civic bodies are working in silos was clearly evident in both states. More vaccination drives and improvement in health infrastructure was evident but sanitation was clearly not getting the same attention.
I was part of a team of experts conducting workshops with journalists and doctors and building bridges of communication between them as well as with the community. While journalists were being given facts and figures and contact details of doctors for accurate reporting, doctors were being told how to avert sensational stories breaking out in the media and also how to deal with reports that create panic in the community. Panic is what most TV reports create with 24 hour channels repeatedly showing grim images of very sick children wearing oxygen masks and wailing mothers. The filth, the stagnant pools of water and poor civic facilities seldom get highlighted.
The vaccination campaigns were being conducted by the Bihar government and in the driver’s seat was the State Institute for Health and Family Welfare (SIHFW).There was so much fear about JE that even bureaucrats and politicians were sending their children for vaccinations.
Although vaccination is the best way to prevent JE, the importance of avoiding mosquito bites was highlighted. To check breeding of the deadly culex mosquito that transmits the JE virus, equal importance was given to prevention of water stagnation around houses and mosquitoes breeding. Cattle and pigs, which are carriers of the JE virus, transmitted by the infected mosquitoes are to be kept at least 5 kms away from homes.
Development paradox: Treating children in the lap of dirt and bacteria
At the best of times, sanitation facilities are a nightmare in Bihar and UP, particularly in the smaller towns. Drains overflow and garbage piles up. However, I was totally unprepared for the sight at the Public Health Society office at Darbhanga. It was a dreary looking building with peeling paint, and right at the entrance were huge puddles of water with pigs and their young ones happily wallowing in the filth. It had rained and accessing the Society office was a nightmare, crossing rivulets of sludge and yes, pigs again. A JE campaign was under away and the top brass in public health from Delhi and Patna were descending on Darbhanga, but no one bothered about the pigs.
Inside the building was a small but important Nutrition Rehabilitation Centre (NRC) of the state government, nursing back to health children who were dangerously underweight. The mothers lived with the infants during the 20 day-treatment cycle where they were given nutrition supplements. Special meals were prepared at the Centre and the experts were weighing the babies regularly to ensure their recovery--gaining 8 to 10 grams per kg of body weight every day or 1.5 to 2 kgs in 20 days. The mothers were being taught how to keep themselves, their babies and the environment around them clean but none of that was being practiced by the health centre.
The NRC, a model for the state, was nowhere near a two-star facility but it was clean, the walls were brightly painted and there was the whiff of phenyl and antiseptics in the air. But what amazed me was how a Centre for undernourished and sickly babies could run in a building that had pigs breeding on its front lawns in a state where JE is rampant. The irony was no one seemed embarrassed or concerned!
An open invitation to disease with drinking water and cooking areas adjacent to open drains
In Gorakhpur UP, which has children keeling over with JE and AES for several years now, not only is there garbage and filth everywhere but hand pumps for drinking water as also the cooking fires are adjacent to drains and gutters. The hand pumps, if shallow, would be pumping water unfit for human consumption. They needed to be moved out and India Mark 2 hand pumps installed in places where contaminated water does not leak into the hand pumps.
The focus of the Central and State governments and the health teams was preventive vaccinations and speedy treatment of AES cases to avert disability and death. According to information provided through an RTI filed by a Delhi University law student and a resident of JE affected Muzaffarpur in Bihar, 6867 people have died of AES in the last six year. Uttar Pradesh was the worst affected with 3422 deaths, followed by Assam, Bihar, West Bengal and Tamil Nadu. Infrastructure and facilities are being improved in 60 endemic districts in these five states.
However, AES and JE are not just medical problems, they are problems aggravated by poor environment--virtually no sanitation facilities. Medical treatment has to go hand-in-hand with improving the environment. Crores of rupees are spent every year in vaccination campaigns and setting up pediatric Intensive Care Units but the impact of these campaigns and facilities gets diminished when the environment is so polluted.
Cleaning the outbacks to be a collective responsibility
The civic authorities have to be strengthened, drains covered, deep hand pumps installed in clean surroundings. The pigs and cattle have to be moved out of residential areas and pools of stagnant water covered with mud.
Swatch Bharat is a wonderful idea but it can become a reality only when the heart of India--our villages and rural outback are cleansed. Serious thought has to be given to generating electricity and organic manure from the piles of garbage. Let us have model villages that are recognised and awarded. A clean environment is the cheapest and most effective way of keeping JE and other disease outbreaks at bay.
Usha Rai is a Delhi-based development journalist who is deeply committed to grassroots issues. She was part of a media sensitisation exercise on routine immunization in the poor performing districts of Uttar Pradesh and had the opportunity to observe areas where there has been high incidence of Japanese Encephalitis.
JE outbreaks are being reported from previously unknown foci. Further, encephalitis outbreaks of other aetiologies in endemic areas have only added to their complexity. For programme managers, researchers and community health professionals, access to accurate and updated information is key to planning interventions and other relief measures.read more