The resilience of the children of Bihar
How do Bihar’s children do so much better than other states, given the odds against them? There is very little research on the positive aspect of low child deaths in the stateUpdated: Jun 29, 2019 19:56 IST
The epidemic of child deaths in Muzaffarpur in Bihar has made been making headlines for the past two weeks. It is tragic that so many children died of Acute Encephalitis Syndrome (AES). Many more are affected and those who survived may have permanent disabilities.
Bihar’s health system has been examined thoroughly by the media and politicians and the bureaucracy have been blamed for neglect of the health system. This is typical after any epidemic or major disaster. It also happened after child deaths in Gorakhpur in Uttar Pradesh some months ago.
Many reasons have been put forth for the AES deaths, including eating litchis that contain a toxin that leads to low blood sugar in malnourished, hungry children, poverty, malnutrition and heat wave. Of course, poor health systems reduce the chance of survival in such emergencies and a shortage of doctors, drugs and equipment, along with poor infrastructure and lack of hygiene, are a norm in most government hospital struggling with issues of lack of funds, poor management and indiscipline.
This has to change. Bihar’s children deserve the same health services as the rest of India. But a positive aspect of child health in Bihar that goes unreported and undiscussed is the children’s resilience.
Along with Uttar Pradesh, Bihar’s health system is the poorest in the country. While other states developed primary health centres (PHCs) to serve a population of 30,000 in 1985 under the Planning Commission’s guidance and support, Bihar still relies on one PHC serving a population of 100,000, with some additional PHCs being created recently.
Bihar also has very few Community Health Centres (CHCs) or rural sub-district hospitals. Take Muzaffarpur district, where the current AES outbreak is going on. It has a population of 5 million, which makes it eligible to have 50 CHCs (rural hospitals with 30 beds each). Instead, its two sub-district hospitals that are understaffed, poorly managed, overcrowded and unhygienic. Doctors also run private practices, which limits their attention to work at the hospital.
Added to these, Bihar’s socioeconomic indicators are terrible, with the country’s lowest state domestic product (SDP) per capita, low education rates, high malnutrition rates, poor infrastructure, gender inequity, law and order problems, among others.
With all these problems, one would expect that the barometer of child health indicators, infant mortality rate (IMR), for Bihar would also be the lowest among states. But that is not the case. Bihar’s infant mortality is 35 per 1,000 live births against India’s average of 33.The IMR for rural Bihar is 36 against rural India’s 37, which indicates children in rural Bihar are healthier on average than children in rural India. Bihar’s IMR rank is 15 among the 21 larger states. It is better than Chhattisgarh, Rajashthan, Uttar Pradesh, Odisha, Assam and Madhya Pradesh, which is not bad at all when you take into account the poverty, malnutrition, poor health systems and other odds against the children.
Rural Bihar’s IMR is the same as that of rural Andhra Pradesh and Gujarat, both of which are more prosperous and advanced states. Immunisation is another example of Bihar’s success, with the state’s coverage of services at par with national level and higher than Uttar Pradesh, Madhya Pradesh and Rajasthan.
How do Bihar’s children do so much better than other states, given the odds against them? There is very little research on the positive aspect of low child deaths in the state. This is what we are terming as “resilience” of children, or perhaps the caring attitudes of their families, who step in when health systems fail. There are lessons for academia and policymakers from Bihar’s children and their families on how to maintain health despite poor socioeconomic and health care systems.
Among the explanations for lower deaths could be a high number of private practitioners — qualified, unqualified or semi-qualified — providing some form of modern treatment, including injecting antibiotics for acute infection. The state’s high population density of about 1,100 persons/sq km would also mean private or public health facilities would be more densely packed than in many other states, which would improve the access and save lives.
It has also been observed but not documented that health-seeking behaviour for childhood illnesses is prompt in Bihar and parents seek available treatment even if it means getting into debt or selling family assets.
We must look more closely at why child mortality in Bihar is comparatively lower in relation to its poor socioeconomic and infrastructure status. There may just be lessons from Bihar for other states.
Dileep Mavalankar is the director, Indian Institute of Public Health, Gandhinagar; Tapasvi Puwar is on the faculty at IIPHG
The views expressed are personal
First Published: Jun 29, 2019 19:56 IST