What’s common between coaching classes in Bihar and its bahubali leaders?

Career Plan Coaching Centre is not much to look at. It is a tiny room, tightly packed with benches and desks, housed in an unplastered brick structure, one half of which is a garage.

A board advertises the services offered by the centre, located in Geetwas, a small village near Araria in northeastern Bihar: tuitions for students between class 8 and class 12.

But, as Gautam Kumar, a mathematics graduate in his mid-twenties who runs the centre, explains, he does not merely provide supplementary education to students lagging in one or two subjects – he teaches the entire school curriculum.

Career Plan is a homegrown response to the larger crisis of public school education in Bihar.

The third — and concluding — article in our series on government functioning in Bihar looks at the aftermath of a state absenting itself.

Bihar’s Nitish Kumar has been in power for 12 years. Why has he failed to change its fortunes?

Kanwar jheel is a freshwater lake spread over 6,311 hectares in Bihar’s Begusarai district. Till the 1970s, the lake used to attract as many as 100,000 freshwater birds each year. But, in recent decades, it has been under attack. Landowners from the Bhumihar caste have been draining Kanwar jheel to farm on its lakebed. This has resulted in protests from local fishermen, belonging to an extremely backward caste called the Sahnis.

What is telling, said Arvind Mishra, an environmentalist who lives in Begusarai, is the government’s reaction. Despite an order by the Patna High Court and appeals from the Sahnis and environmentalists, it has not intervened.

The fallout: Sahnis, who are seeing their fish catch fall, are hunting birds instead. Between that and the habitat loss, the number of birds coming to Kanwar jheel has fallen to 4,500-5,000 each year, he said.

What explains the lack of government response?

The second part of our trilogy on why Bihar underperforms on the welfare and development front.

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.

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.

Why Odisha sees little protest despite the state’s poor public services

Stay in Odisha for a bit and you will run into a puzzle.

Despite healthy finances, the state is failing to provide basic services to its people. Its schools and hospitals are badly understaffed. Jobs are not easy to find, as a result of which young people are getting disillusioned with education itself. Welfare programmes like the National Rural Employment Guarantee Scheme work only on paper.

While the state saw an iron ore boom over the last decade, government’s policies ensured only a handful of people became rich. Most stayed unaffected. Some ended up poorer. During the same period, the state also saw a chit fund boom in which middle- and low-income families lost money.

Despite this streak of state failure, the state’s people continue to be silent.

a wrap of all our #eartotheground reporting from odisha. this is the second wrap — the first was on mizoram.