What happened in Gorakhpur in 2005.From The Guardian’s archives.
Kiran Kumari has been sick for more than a week. Now, lying in a sweltering, overcrowded hospital ward, the skinny 11-year-old with the copper-streaked hair has lapsed into unconsciousness and can no longer breathe on her own. So her father is breathing for her.
Sitting on the edge of her thin mattress, his face a taut mask of exhaustion, the destitute farmworker rhythmically squeezes a football-sized plastic ventilator with his callused hands, forcing air into her lungs with every pump.
Such life-saving duties are normally left to professionals, but in this case there are not enough to go round. Over the past two months hospitals in the northern state of Uttar Pradesh have been overwhelmed by Japanese encephalitis, a viral infection that has attacked more than 2,000 children and killed nearly 600, making it one of the deadliest outbreaks of the disease on record in India.
In this city at the heart of the epidemic desperately ill children crowd two or three to a bed, with family members camped in filthy corridors. Weary medical staff struggle to keep pace with about 30 new cases a day. Japanese encephalitis kills nearly 30% of its victims, mostly children under 15, and leaves many of the rest with permanent neurological damage.
The toll is all the more heartbreaking because the disease can be prevented by several vaccines, including one made in India and a more effective version developed in the 1970s in China, where mass vaccinations have largely contained the virus.
The latest outbreak shows how bureaucratic inertia, skewed priorities and what some health experts say is a nationalistic aversion to importing medicines are undercutting efforts to improve India’s shaky public health system, to the detriment of its poorest citizens.
This month in its annual human development report the UN criticised India for falling behind on key public health goals, noting that its infant mortality rate is higher than that of Bangladesh. One in 11 Indian children dies before the age of five.
“It’s a lot of politics in vaccine,” says Komal Prasad Kushwaha, a senior pediatrician at the hospital who has watched in frustration as the death toll from Japanese encephalitis in India has climbed steadily over the past two decades. “We have been crying for vaccine since very long. If vaccine is available for all children in the community, Japanese encephalitis will certainly be controlled.”
Health officials in Uttar Pradesh say they are trying to contain the epidemic by spraying against mosquitoes, which typically acquire the virus from pigs before passing it on to humans. Over the longer term they are trying to shift pig farms, which can act as reservoirs for the disease, away from crowded villages.
The Indian health minister, Anbumani Ramadoss, has said he wants to remove barriers to the importing of Japanese encephalitis vaccines in time to begin mass vaccinations in high-risk areas by April, before the disease makes its seasonal reappearance. Ramadoss and his aides did not respond to phone messages and two faxed requests for comment.
Japanese encephalitis occurs across wide areas in Asia, where about 50,000 cases – and 15,000 deaths – are reported annually, according to the World Health Organisation, although the number of cases is thought to be vastly underreported. In India the virus is concentrated in eastern Uttar Pradesh, the country’s most populous state and one of its poorest, and the states of Andhra Pradesh and Assam.
In some respects India should be well-equipped to contain the threat. Its cutting-edge pharmaceutical industry supplies life-saving medicines – including measles vaccine and anti-retroviral drugs used to fight Aids – to much of the developing world; a government research institute has made a Japanese encephalitis vaccine for years.
But the Indian vaccine is expensive, time-consuming to produce and relatively short-lived in its effectiveness. Because the government has resisted importing better versions from China and elsewhere, or licensing their production at home, India has adopted what Julie Jacobson, a virologist, calls a “firefighting approach” to Japanese encephalitis, ramping up domestic vaccine production in response to each outbreak, by which time it is often too late.
“It’s just amazing that with that kind of technical capability, the problem of Japanese encephalitis has not been solved” in India, Jacobson says in a telephone interview from Seattle, where she directs a $27m Japanese encephalitis initiative for the Program for Appropriate Technology in Health, a nongovernmental group. The effort is funded by the Bill & Melinda Gates Foundation. “It hasn’t been a high enough priority,” adds Jacobson, although she says the 15-month-old government of Prime Minister Manmohan Singh is “very interested in moving forward right now and solving this problem”.
The human costs of the latest outbreak are all too evident in Gorakhpur, a city of about 300,000 650km miles east of the capital, New Delhi, on the swampy sub-Himalayan plain near the border with Nepal. Since late July the epidemic has been raging in the poor farming villages that surround the city, where the public BRD Medical College hospital has treated most of the young victims.
Because there is no cure for the disease, medical staff can try only to ease its symptoms, providing drugs to treat fevers and convulsions or inserting feeding tubes when children become unconscious. A grimy four-storey building whose grounds are covered in weeds and rubbish, the hospital is treating about 230 encephalitis patients in three wards with a bed capacity of 180, according to Kushwaha.
Children at the hospital are dying at the rate of about one every two hours. Doctors and nurses are in such short supply that in many cases parents are the only ones keeping their unconscious children alive, using foot-operated suction pumps, for example, to clear airways of mucus and saliva. But the mostly illiterate villagers are not always up to the task. Bhupendra Sharma, a senior resident physician, says more than half of the deaths in the encephalitis wards are caused by aspiration choking, which occurs when the internal airway is blocked.
The sickest patients are in Ward 6. Mothers in colourful saris and fathers in simple work clothes cluster around their mostly inert children, sometimes sponging their feverish bodies with damp cloths. A few doze on straw mats unrolled beneath iron-framed beds. Some children breathe through oxygen masks.
Kiran Kumari, the 11-year-old, lived with her parents and six siblings in a mud-and-straw hut about 65km from Gorakhpur. After she began having seizures her parents and teenage sister brought her to the hospital in a motorised rickshaw. Several days later, when she became unconscious, medical staff inserted a plastic tube in her airway and showed her family how to use the hand-operated ventilator, as the mechanical ones were all taken.
“For four days we haven’t been able to eat or cook any food,” says Kumari’s mother, Gulaicha Devi, a slight, careworn 40-year-old. “We’re so tired. We didn’t bring anything with us. Not a glass of water to drink from. Not a change of clothes.”
Despite their exhaustion Kiran’s parents and sister keep substituting for each other on the ventilator, refusing to give up hope. It is no use. The next morning they and their daughter are nowhere to be found. Another sick child has taken her bed. A doctor says the girl died at 5.15am.
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