fractured earth

Bihar is struggling to improve the lives of the poor even after 27 years of backward caste rule

The district hospital of Muzaffarpur, 100 km north of Patna, Bihar’s capital, is struggling with a shortage of doctors.

With 160 beds and an estimated inflow of 500-600 new patients each day, the hospital should have 48 full-time doctors and 52 nurses, said one of its administrators. What it has, instead, is 12 full-time doctors, 24 part-time doctors and 28 nurses. The Intensive Care Unit should have four doctors but has just one. The unit for newborn babies, which should have four pediatricians, is managing with just one.

Given such understaffing, the hospital doesn’t meet the district’s healthcare needs.

When Madina Begum, a resident of Ratnauli village, took a neighbour with a temperature of 104 degrees Fahrenheit to the hospital, she said, “All the doctors did was give her a bottle of saline. Nothing else. No medicine.” The woman’s companions had to put wet clothes on her all night to cool the fever down.

That is the story across Bihar. Seventy years after Independence, the state’s healthcare infrastructure continues to be grossly inadequate. Seventeen of the 38 districts in the state have no more than three government doctors for every 100,000 people. One district, Siwan, has just one doctor for 100,000 people. The highest, Sheikhpura, has eight doctors per 100,000 – or one for every 12,500 people. To put that in perspective, the WHO-prescribed level is 1:1,000.

In the same way, while the Right To Education law mandates student-teacher ratios at 30:1 in primary schools and 35:1 in upper primary, the ratio in Bihar districts hovers between 43:1 and 96:1. As a result, learning outcomes are poor in the state.

All of which echoes what we saw — in relatively greater detail — in the state’s remarkably inadequate response to both arsenic contamination of groundwater and the rising incidence of dengue. Embedded in all this is a paradox. In the last 12 years under chief minister Nitish Kumar, as the article says, Bihar has notched up large improvements in law and order, road connectivity and electricity supply. But its performance on issues crucial for the poor – like health, education and land redistribution – remains weak.

Which is odd. In the last 27 years, the state has been ruled by backward caste leaders, who rose to power by appealing to the poor. Given that, why is Bihar’s track record on crucial issues that most affect the poor so underwhelming?

Out today is the first of a three-part answer to that question.

How technology is changing popular culture in Bihar

Sudhanshu is hard at work in his shop on Patna’s busy Boring Road. The small strip of a shop has two desktop computers, both loaded with music and movies downloaded from the internet.

The songs and films are Sudhanshu’s livelihood. Boring Road, with its government college and several dozen coaching centres, is a beehive of students. Every day, several of them visit the shop to purchase the latest movies and songs for their phones and pen drives.

One sleepy afternoon in March, Sudhanshu, who does not look older than 20, rattled off the names of the hit movies of the moment: Akhil The Power of Jua, Heart Attack, Businessman 2, Shivam, Viraat, The Return of Raju. All South Indian films, mostly Telugu, dubbed into Hindi for audiences in the north.

“We have more people coming here for Tamil and Telugu films than for films in other languages,” Sudhanshu said. Apparently, South Indian films have soared in popularity in the last five years. And not just in Patna. At an autorickshaw stand outside the Jawaharlal Nehru Medical College Hospital in Bhagalpur city on another March afternoon, two young men were watching a movie on a mobile phone.

Which film? “Tamil hai,” one of them replied. It is Tamil.

Wait! Why are people in Bihar watching Tamil/Telugu movies all of a sudden? Read on.

What Bihar’s changing village bazaars say about the state

Village markets are changing in Bihar — as they are in the other states #ETTG reported from. This piece looks at some of those changes — and advances hypotheses to explain these changes.

Bihar can’t even count how many dengue cases it has had, let alone fight the disease

In Bhagalpur, the historic Bihar city on the southern banks of the river Ganga, doctors disagree about the threat of dengue in the area. Vijay Kumar, the civil surgeon for Bhagalpur, says dengue is under control. His statement has been flatly contradicted by doctors at Bhagalpur’s Jawaharlal Nehru Medical College and Hospital. The hospital identified its first dengue case about four or five years ago. Since then, said an administrator, the number of cases has grown. “We had 441 confirmed cases last year – almost double from the previous year.”

Bihar’s exposure to dengue is relatively recent but the state needs to start fighting the disease. Fighting dengue can be easy because there are clear measures that need to be taken. Since there is no cure and no vaccines for the disease, doctors can only treat symptoms – pain, chills, fever, nausea and vomiting, rashes and bleeding. In most cases the disease subsides but a few cases may be so severe that without hospitalisation and treatment it can lead to death. If a patient has excessive bleeding or a very low platelet count he might be given a platelet infusion.

But fighting dengue is also difficult because it requires meticulous and consistent control of the Aedes aegypti mosquitoes – the main species of mosquitoes that carry and spread the dengue virus. This can be done using anti-mosquito sprays to kill the mosquitoes that are normally active during the day. Dengue control also involves thwarting the mosquitoes from breeding, which can be done by reducing places – any stagnant water – where they can lay eggs. To ensure this, regular water supply is essential so that people stock less water. Also important is good garbage disposal.

Given the meticulous work needed to combat diseases like Dengue, how is Bihar doing? And what does its response tell us about the state?

Lessons from Bihar’s 2016 dengue outbreak : Migration, poverty, garbage are spreading new diseases

In 2016, dengue hammered Krah. As many as 100 people living in this densely-packed, predominantly Muslim ghetto of about 1,000 families near Biharsharif contracted the disease, say residents. The scale of the outbreak was unprecedented. As Mohammad Ilyas, a young tailor who works and lives in Krah, said: “We never had such an outbreak earlier.”

The disease itself is a newcomer to the region. Krah and surrounding areas have been battered by many diseases. But many of the old diseases are in decline now, according to Dr Lakshmi Chaudhary who runs a clinic in adjacent Silao. “There were only two-three cases of jaundice last year,” he said. “Hepatitis B is even lower. We now almost never see cases of diarrhoea.”

Here, people now suffer from other ailments. There is more cancer, dengue and chikungunya, said Chaudhary.

This is the story across Bihar. Doctors, epidemiologists and people living across the state say that in the last ten years the state’s disease burden has seen three large changes. First, some infectious diseases like kala azar, measles, diphtheria, pertussis and polio that used to wreak havoc earlier are far less common now. Second, people are falling to new diseases like drug-resistant tuberculosis, dengue, chikungunya, Japanese encephalitis and arsenic poisoning. Third, some of the old infectious diseases – hepatitis A and E, malaria, pneumococcal meningitis and typhoid – are claiming more patients than before.

This, as the article says, is very different from the epidemiological transitions in other states. And gets into the reasons why. Part two, out tomorrow, will look at the state’s response to these causal factors.

Cancer has exploded in Bihar as lakhs of people drink water poisoned with arsenic

It is a day like any other at Mahavir Cancer Sansthan.

The driveway is lined with people who have travelled a long way to get to this charitable hospital in Patna. Families sit huddled, holding their bags close. The lobby is even more crowded, rather like the ticket buying hall of a train station.  The hospital gets between 60 and 100 patients every day – a substantial number for a 400-bed hospital. Ashok Ghosh, who heads research at the hospital, said that the load is such that “surgery has a two-month waiting list even though the disease might become inoperable by then”.

On the morning this reporter met him, Ghosh made a wry comment about the rush, asking: “When you entered this hospital, did this look like a cancer hospital or a general hospital?”

One reason this hospital is receiving so many patients is the dismal state of public healthcare in Bihar. Government hospitals are understaffed and poorly equipped. While the state has seen a jump in the number of private hospitals, most of them are too expensive for middle income and poor families in the state. Most of them, Ghosh said, end up coming to Mahavir Cancer Sansthan.

But lack of affordable care is not the only reason. Tata Memorial Hospital in Mumbai, one of the best cancer treatment facilities in India, gets about 25,000 patients every year from around the country. In contrast, Mahavir Cancer Sansthan gets nearly as many at about 22,000 patients last year despite drawing patients from just Bihar, Uttar Pradesh and Nepal. Many of these patients suffer from cancers of the gall bladder or liver, both which are associated with arsenic toxicity.

And now for something completely different

This year’s EOTY (end of the year) bike ride started at Guwahati, Assam, and ended at Miao, Arunachal Pradesh. The route (Guwahati, Mangaldoi, Dekhiajuli, Pabhoi, Majuli, Sibasagar, the coaltown of Margarita, Miao, followed by a visit to Namdapha Tiger Reserve) stretched along the north bank of the Brahmaputra till the river island of Majuli and then crossed over to the south bank before entering Arunachal. Moving from west to east, Assam seemed to change from day to day. The profile of the local population gradually changed (from Bengali influences to Muslim dominated to Axomiya hindus to a greater tribal composition as one neared the Arunachal border). As did the houses, diets and local markets.

Some pictures. That snap you see on top left is the endangered Pygmy Hog. The beneficiary of what is described by my biologist friends as India’s only successful wildlife reintroduction programme. The two snaps below it were taken as we (three friends and me) pedalled towards Majuli. The snap of haystacks in the middle was taken on the second day — en route to Orang National Park. The snap on the top right? That is the sort of house we saw in the initial days — houses with attached fishponds.

The snap of a bridge, mustard fields and the setting sun? That was taken en route to the ferry for Majuli (which stars in the next snap). The two misty snaps were taken the next morning in Majuli as we cycled to catch a ferry from Majuli’s eastern bank. That was a morning to remember — us cycling on the fine sand of the Brahmaputra’s riverbed, with the mist swallowing up everything beyond 20 or so metres. The next snap, of my sand encrusted cycle, was taken after this ride.

That shack you see was a place where we breakfasted shortly after getting off the ferry. The gent wearing the adidas sweatshirt was running that eatery along with his wife. The two people below him? We met them, at another tea-stall, on the way out of Sibasagar. Ditto for the young man from Bihar selling cakes, puffs and pastries from his cart. Around here, the houses had changed. We saw fewer houses with ponds. Most houses had a canal running out in front with these cane bridges over them.

Then came Margarita. And that is where the next set of snaps — like that of the vegetable sellers, including the one with the coal mine in the background — were taken. Around here, the houses (and the profile of the local population) had changed yet again. And then, we entered Miao. The vertical snap you see was taken inside Namdapha Tiger Reserve. The rest were taken in local markets in this part of Arunachal — the first set of women are selling, among other things, local turmeric. Rs 10 for each page’s worth. In the snap to the right, you will see what looks like white cookies in plastic bags. That is yeast, using for making local rice beer called Loh-Paani.

In the final snap, the woman holding up that newspaper belongs to the Apatani tribe — look at the facial tattoos. She was eating jalebis when I took that snap. This, of course, is little more than a random sampling of snaps. That week of cycling left us with more impressions than what a quickly-written blogpost can handle.

PS: It was a good break. No email. The phone on DND. The brain caught a break from its usual ADD, spending hours at a stretch cycling or reading. Two notable books from this trip: Jon Prochnau on the adversarial reportage by David Halberstam, Neil Sheehan, Mal Browne and others during the early days of the American quagmire in Vietnam. And another on Aristotle’s staggeringly accurate (and sweeping) effort to make sense of life’s diversity on Earth.

PS: You will have to forgive me the multiple snaps of my cycle — my Surly Cross-Check is tough and beautiful. And I keep photographing it.

PS: And here is a blogpost on the trip by my fellow cyclist Vidya Athreya.

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