Two hospitals, one enemy: A deep dive into how medical professionals are dealing with AES

The north-western district of Muzaffarpur is the epicentre of the Acute Encephalitis Syndrome (AES) outbreak in Bihar. The government estimates that as of June 24, 130 children across the state have died in two hospitals in Muzaffarpur, one government and one private: Sri Krishna Medical College and Hospital (SKMCH) and Krishnadevi Deviprasad Kejriwal Maternity Hospital (KDKM).

Seventy per cent of the staggering 594 AES cases in Bihar are from Muzaffarpur alone, and the rest from 10 other districts including the neighbouring East Champaran and Sitamarhi. 

Medical professionals—nurses, junior doctors, senior doctors—rue that “mismanagement” spiked the intensity of the AES outbreak this year. In a bid to now “manage” the crisis, doctors from around the country have been flown into Muzaffarpur. About 100 students from a local nursing college have had their classes dropped so that they can work round the clock at SKMCH. A dozen final year students from a local medical college have also volunteered to work in 10-hour shifts to assist senior doctors. In Public Health Units (PHUs) located in smaller towns outside Muzaffarpur, doctors and nurses have hurried in from other districts after instant transfer orders from the state government.

Sri Krishna Medical College and Hospital (SKMCH)

SKMCH is simply known as “medical college” in Muzaffarpur. Situated some eight kilometres outside the bustle of the main town, it is considered the most well-equipped institution in Bihar to deal with AES. Packed with 8-10 ambulances, it has a tent setup outside it to deal with the increasing number of people who have come to occupy the corridors of its three floors in the last few weeks.

Sri Krishna Medical College and Hospital (SKMCH) in Muzaffarpur.

According to government records, 436 cases of AES have been brought to the SKMCH as of June 26; 290 have been discharged, and 111 have died here.

The hospital follows the government-drafted standard procedure to treat AES. Children here are being treated for three main symptoms of the syndrome: heat stroke, high fever and convulsions. Patients are administered paracetamol for the fever, and are admitted in air-conditioned pediatric intensive care units (PICU) with a wet cloth around them to treat the heat stroke. For convulsions, they are given “first line drugs”, “second line drugs” and anaesthesia.

If these do not suffice, the doctors need life-saving ICU equipment like centralised oxygen systems and Cardio-Pulmonary Resuscitation (CPR) machines, which SKMCH does not have. Instead, oxygen cylinders can be seen ferried in and out of these wards. 

Doctors in the hospital have not been authorised to speak to the media, especially after an ugly episode transpired between a doctor and a television anchor last week. (“The media does not need to know everything,” Sunil Kumar Shahi, the hospital’s superintendent, told Newslaundry.)

On condition of anonymity, a doctor tells me that AES might not be as serious a disease as the press is making it out to be: “Those who brought their children to the hospital within an hour of observing AES symptoms have been treated within a couple hours and sent back.” This crucial window of time is dubbed the “golden hour”. 

Around Muzaffarpur, at least until a week ago, parents from rural regions first took their children to a local private institution or an ill-equipped PHU in the nearest town. By the time they were “referred” to SKMCH, the child did not survive.

There are 35-40 doctors at SKMCH who are authorised to treat AES with the assistance of around 200 nurses. They work in three shifts: 8 am – 3 pm, 3 pm – 10 pm and 10 pm – 8 am. The final year students assisting them have been handed a 9 am – 12 pm shift on paper, but end up working between 8 am and 6 pm. 

Parents with children in “stable” condition have camped in a separate ward in the hospital. There are no air conditioners here but one can count about six air coolers. This ward has 40 beds, with every family—usually three to four people—on each bed. The rest are crowded on the floor. The ward has around 200 people in it and three nurses managing affairs. One nurse looks after all 40 beds. Security officials of the hospital walk around, asking that only one family member stays with affected children and the rest leave. A local MLA also does the rounds.

The hospital ward at SKMCH with families and children in “stable condition”.

In this ward I meet Nirale, who runs a business selling bangles in Delhi’s Paharganj. Nirale was in Muzaffarpur to attend a relative’s wedding. Everything seemed fine, until one morning when his eight-year-old daughter woke up with a “spinning head”. At a local clinic, Nirale was handed three things: medicines, a “referral” to SKMCH, and a bill of ₹6,000. 

An X-ray at SKMCH—which costs ₹900—showed that his daughter’s skull “did not reveal any significant abnormality”. The child was still kept on a drip. A sombre Nirale tells me he had talked to a doctor in Delhi and wanted to take his daughter there by the first flight the next day. He did not. The next morning, his daughter was diagnosed with AES and Nirale spent his day beside her in the PICU ward.

Nirale points out the distinction between an in-house doctor and one brought in from outside: “One of the doctors here had taken a liquid sample from my daughter’s spine; it had to go for a lab test. For 24 hours, I just saw the liquid lying in the ward for no purpose. I then told a doctor who came from Delhi to look into it. He sternly prompted the management and the sample was sent to a lab within an hour.” 

Till June 16, SKMCH had four PICU wards with 50 beds between them. On June 16, when Union Minister Dr Harsh Vardhan showed up, it set up another unit with 16 beds, 16 brand new monitoring machines and eight air conditioners. Chief Minister Nitish Kumar was scheduled to visit the hospital on June 17. 

To strengthen operations in the hour of emergency as well as to avoid ruckus when high-profile individuals arrive at the hospital, 35 police personnel from the local police and 120 retired Army officials working for a private security company calls Goswami Security Service have been stationed in the premises.

Since it rained on June 22 and the cases dropped, one child per bed has started becoming the norm. But in the older wards like PICU 1, there are still 10 children adjusted in eight beds. Another ward with 20 beds is ready, though no patients have been admitted there. Shahi says there are no patients to be admitted in the ward as of now. “Pray that there is no need to do so either,” he says. The doctor, however, tells me that the ward will start functioning only the next day.

A new ward in the hospital that a doctor says is yet to begin functioning.

While the hygiene in these wards is decent, it is dismal in the rest of the hospital. Outside the PICU wards, the institution’s dimly-lit corridors are littered, populated and in a state of squalor. It’s hard to miss the scattered clothes, plastic bottles, footwear, gravel and food. People sit, talk, walk, vomit and sleep on the floor—emaciated, plaintive and visibly unwell. The windows in the corridors open up to a dark verandah-like space where garbage mixes with algae.

The corridor on the ground floor of  Sri Krishna Medical College and Hospital.

The management is clearly nervous about the abysmal hygiene in the hospital. In a doctors’ meet in the hospital’s other-worldly air-conditioned seminar room, a well-spoken senior doctor in his seventies addresses the hospital’s management and other doctors—around six men and two women. The sartorial finesse and the spoken English indicate that these are the doctors brought in from around the country, including Patna.

Bringing up the poor state of hygiene, the senior doctor asks one of the officials if he can take up the responsibility of cleaning up the place. “No sir,” the official stutters anxiously, “I already have too many responsibilities and pending tasks.” Disappointed, the doctor turns to another official with a “Ministry of Home Affairs” identity card around his neck. This one too has his own tale of woe.

The verandah besides the hospital corridors where all the trash is collected.

One doctor points out how the local private hospitals are charging poor families ₹5,000 for basic medication. “We cannot fight the corruption,” responds the senior doctor, “we have to work within the system.”

Krishnadevi Deviprasad Kejriwal Maternity Hospital (KDKM)

KDKM, or Kejriwal hospital as its simply known in Muzaffarpur, is situated within the town.

Government records show that 165 of the 601 cases of AES have been brought to the three-storey KDKM as of June 26; 77 have been discharged but 21 children did not survive. The hospital currently has six AES patients under treatment.

Krishnadevi Deviprasad Kejriwal Maternity Hospital, Muzaffarpur.

On its worst day, June 17, the hospital had 19 children brought in for AES. Two of them died.

The institution has three of its own ambulances (and a fourth one recently provided by the government) and an in-house security personnel with a strength of 30. 

There are 15 resident doctors at KDKM who are authorised to treat AES, assisted by around 30 nurses. At any time, three doctors are always present for AES patients. Their shifts are the same as those at SKMCH. However, police personnel and private security haven’t been stationed at this hospital. One reason for this is that none of the politicians or celebrities made an appearance at KDKM. Second, KDKM is smaller, most congested, but without as many people in its corridors as SKMCH. It has 32 beds for AES, and eight extra ones leased out for emergency last week.

Patients’ families in the corridors of the KDKM hospital, Muzaffarpur.

The AES ward at KDKM hospital, Muzaffarpur.

However, it is comparatively better staffed and perhaps better resourced—which explains why doctors and medical students haven’t been brought in here. Unlike the larger hospital, it also has a centralised oxygen system.

The first and second floors of the hospital are reserved for treating women, while children are brought to the third floor. The first two floors badly-lit and relatively dirty, but the third floor (especially the area with the AES ward) is well-lit with a cleaner white-tiled floor. 

The second floor of the KDKM was much dirtier than the third floor which has the AES ward.

Rakesh, who has worked as a compounder at the hospital for 12 years, says the place has been cleaner in recent days than it has ever been before. He says: “It’s because the CM and [Dr] Harsh Vardhan came to Muzaffarpur.” He adds that KDKM is run by a not-for-profit charitable trust so the staff here is not that well-paid: “We don’t get much money but that’s secondary, especially with this emergency going on.”

But for a private institution, KDKM has been providing free of cost treatment to families with children suffering from AES. “The hospital only charges a consultation fee of ₹150. But for AES, even that is waived. We provide children khichdi and milk for free too.”

Rakesh believes that the AES outbreak was caused because of lack of jagrukta (awareness) among the people in Bihar. “In rural schools, a master scolds a child whenever he defecates in the open. They are given orders to do so. The same should be done to prevent them from going into the sun. They should be asked to wear slippers. The government should do this and the numbers will definitely drop.”

In the past 20 days, Rakesh has seen 20 children die in the ward where he sits everyday. “I don’t get to feel too many emotions, sir. It’s an emergency, so everyone has left everything and we work on this throughout the day. Expressing sorrow over dead children will not bring them back to life, will it?” he asks, without making eye contact and looking down at the floor.

Rakesh, who has been a compounder at KDKM for 12 years.

When I visit, five children are admitted at the ward. The youngest, only one year old, is breathing so heavily that his chest doubles in size whenever he inhales. The hospital’s Dr Chaitanya tends to each patient in turn.

“The agent of this syndrome is unknown. But in all cases we witness that their blood sugar level drops,” Dr Chaitanya tells Newslaundry. “Our treatment is to make sure that it does not drop to fatal levels, else it can kill brain cells at a tremendous speed.” He adds: “The hosts of the syndrome, however, are always those who are socio-economically deprived.”

A couple sit in one corner of the AES ward, solemnly counting currency notes. Suninder Manjhi sits in another corner; his three-year-old nephew Bobby lies unconscious on a bed in the ward, and the uncle is here to look after him. This is Suninder’s third day at the hospital. “His father, my brother, asked me and a second brother to take turns and look after the child. He is away because he works on a farm in Punjab,” Suninder tells me. 

Suninder Manjhi, whose three-year-old nephew is admitted at KDKM’s AES ward.

Suninder says there was another boy in their village in Muzaffarpur who showed symptoms of AES. He died by the time the family reached the “ambulance spot”. 

Suninder is a labourer and makes ₹200-300 everyday. “I was away at work so I don’t know whether he played under the sun. You should ask his mother that question.” But where is the mother? “She would look at him and cry so much that we sent her back to the village.”

Coda

The ongoing medical efforts in SKMCH have improved in the past few days. But this is largely due to the spell of rain in the district on June 22 and the relatively cooler temperatures since. 

Purely in terms of management, SKMCH has not done well. That it had to get nurses from a local college in addition to doctors from the rest of the country is enough to demonstrate the cold shoulder that the government institution gave to its responsibilities. Moreover, the squalor within its premises—only metres away from patients and their families—throughout the outbreak was salt in the wounds of those who rushed to the hospital from the rural corners of Bihar.

While KDKM was a better study in this regard, the institution had half the capacity to deal with AES when compared to SKMCH. And even those cases which did come to this hospital first were often “referred” to the government hospital.

The extensive medical mobilisation at the two hospitals since the beginning of the outbreak impinges on the larger state of healthcare in Bihar. If medical emergencies continue to be dealt with through mobilisation and relocation, what about the thousands of non-AES patients who languish in the state’s hospitals and health centres? They are undeniably the victims of this transfer of medical supervision and human resources.

At a Public Health Centre in the small town of Kanti in Muzaffarpur district, a doctor transferred from the neighbouring district of Darbhanga bemoans the state of a serious patient he was supervising 24 hours before. He asks, “I might save one life here, but what about the one I left behind?”