Brahmaputra’s orphans

The yearly floods expose Assam's fragile health care system.

As the plane prepared to land at Dibrugarh on the southern bank of the Brahmaputra, Assam looked like an ocean. The mighty river had overflowed. Paddy fields and villages lay submerged as far as the eye could see. Entire communities, along with their livestock, were living perched on bamboo platforms on stilts or changs.

Statistics on Assam's annual floods rarely reveal the true tragedies that engulf the lives of people in this troubled and neglected part of India. As elsewhere, the state has abdicated its responsibility in providing health care and health education to the poor. Elsewhere in India, public philanthropy at least may work to provide some facilities for the poor, but here in India's Northeast they just die quietly.

Embankments built to contain Assam's rivers breach regularly and as the flood waters rise and fall, epidemics of gastroenteritis, malaria and Japanese encephalitis rampage through upper Assam. The state's public health services are incapable of dealing with the situation. Added to the absence of basic life-saving drugs, is a general ignorance on all health matters.

Of course, Assam does not lack in public resources for investment in the social sectors. It is poor political leadership that keeps a well-conceived public health policy at bay, which is why the population of the state is one of the unhealthiest in the Indian Union. The floods only make a bad situation far, far worse.

Even as the state was reeling under a spate of epidemics during the floods in the summer of 1998, there appeared to be a deliberate attempt to under-report its extent. The state officials claimed there were adequate supplies of drugs and services and that the infrastructure was in place for their distribution. To take just one case of Lakhimpur district, the officials claimed there was no shortage of drugs. Only upon being challenged by those who had visited the Civil Hospital ward and interviewed the patients, did they concede that the patients were buying even basic drugs from private pharmacies. The hospital stores revealed barren shelves. Lakhimpurs main hospital did not have antiseptics, detergents, bleaching powder, or even paper for writing prescriptions and soap for the doctors.

Doctored data

There was also brazen doctoring of data. Although Lakhimpur lies in an area prone to the deadly cerebral malaria, official records would have you believe that there had not been a single death from malaria or Japanese encephalitis since 1995. Japanese encephalitis is endemic to the northern bank of the Brahmaputra and major outbreaks were recorded over the entire decade previously. The records also point to a suspicious disappearance of the disease between 1995 and 1997. Not a single case of infection or death was recorded. This is the cheerful picture available from the Assam-wide records maintained by the Director of Health Services in Guwahati. Look a little deeper, and you realise that of Assam's 23 districts, there is no data presented from 13 districts.

The government papers may record no cases of Japanese encephalitis, but on a recent visit, 19 patients of suspected Japanese encephalitis were found languishing in government-run institutions in Dhemaji and Lakhimpur districts. Health authorities did not even know they had a serious outbreak in their hands. Although India has developed a vaccine against the infection and 70 percent of the population in Assam's endemic areas have been vaccinated, the required booster doses have not been provided. N.C. Das, chief medical and health officer for communicable diseases in Lakhimpur, says, "We are handicapped and helpless. We cannot even provide syringes for the vaccine, there are no vehicles, or money for petrol. I have sent reports to the government on what should be done, but the politicians do not consider what we are saying."

Preventive health education is absent in tribal areas where the disease is prevalent. Pigs are known to be carriers of the Japanese encephalitis virus, and the pigs reared by the tribals move in with the people up into the changs during floods. At the public hospitals in Dhemaji and Lakhimpur, Japanese encephalitis patients were being treated on the basis of symptoms since confirmatory tests could not be done. There were no vital drugs in these hospitals where medicines are supposed to be distributed free, so some poor families had spent over INR 5000 (USD 110) for medicines and food in a week. At a time when they had already lost their annual crop of paddy in the floods, this was a vicious blow.

The local residents speak of the Gogamukh rural hospital in Dhemaji district as being a slice of the whole picture. The 30-bed hospital, catering to a population of 200,000, has only six beds. One patient was lying on a narrow wooden bench, while the bed of another was propped up by a wooden crutch. The hospital has no water or electricity, and the delivery room is a dark, windowless, smelly dungeon. Since there is no other alternative, up to 400 people visit this hospital every day for treatment.

The plight of tuberculosis patients is worse than those suffering from Japanese encephalitis. In the Mangaldoi district village of Dhulla, with a predominantly Bengali-Muslim population, virtually every house is ravaged by TB. The government TB centres have run out of even the basic reagents for testing sputum, and patients are directed to private clinics where they pay up to INR 300 for an X-ray.

Once again, drugs meant for free distribution are never available. The standard drug regimen, approved by the national TB programme, requires patients to take a combination of at least five drugs, but the patients at Dhulla said they had received only two drugs: Streptomycin injections and Isonex tablets. Unless the therapy is completed, the TB virus develops drug resistance, forcing the patient to a second and much more expensive line of treatment.

Ever)' time patients run out of money, treatment is terminated. What drugs they can afford they buy from private pharmacies, where it is likely they end up getting the wrong treatment because of incorrect prescriptions. A local government doctors prescription for TB consisted of Calmpose injections and cough syrup.

In the TB ward of the Mangaldoi Civil Hospital, 25-year-old Sibiya Marak lies dying. He had sold his last two bullocks in his hospital treatment. Little does he know that the two drugs provided to him by the hospital, improperly administered, have actually deprived him of all chances of survival.

Officially, there were over 1.2 million TB cases under treatment in Assam in 1997-98, but records show that the state received only three of the five essential drugs required for TB treatment from the central government. On top of it all, the supply is not enough for more than 100,000 patients. Vital and expensive medicines like Rifampicin and Pyrazinamide have not been available for years.

As part of the treatment, doctors routinely tell poor villagers to eat chicken, eggs, fruits, and to drink milk and take vitamin syrup. "But where do I find the money for them?" asks Zaida, a TB patient.

Halima Rehman is a social worker in Dhulla. She says, "The Bengali Muslim community here is pathetically ignorant. They eat fermented rice, red chillies and dried fish. Although this area grows green vegetables and seasonal fruits, it is not a part of their daily diet, because nobody has explained to them their nutritional value. TB is rampant here, and people desperately need correct information and help."

Sick and neglected

Assam desperately needs strong curative services and preventive health education. In all of India, the state has the highest death rate among children below five years of age. It lags far behind the national average in male and female life expectancy.

Ironically, economists in Guwahati are categorical that Assam does not lack resources for social sector development. For instance, Assam spends 1NR 46 per capita in the social sectors. Even so, it is backward in health compared to neighbours like West Bengal, which spends only 1NR 36.32 per capita. To take another indicator, West Bengal has covered 84.9 percent of rural households with drinking water facilities, while Assam has managed only 43.2 percent.

According to Jayanta Madhab, chairman of the North Eastern Development Finance Corporation, the Centre transferred 1NR 490 billion (c USD 11 billion) to the Northeast between 1991-1997. Of this, Assam alone got INR 180 billion. But most of this amount was consumed in salaries and pensions to government employees. Barely 10-15 percent remained for development work, which was so spread out that nothing much could be achieved.

In a region wracked by separatist movements, any responsible government would have understood the obvious importance of providing basic education and health facilities, if only to send a message to the numerous small nationalities that they are indeed valued members of the larger nation. The Northeast is rich in its traditional skills and natural resources and its people do not require much to get on their feet. By persistently ignoring their needs, the ruling elite of the region and the uncaring politicians and bureaucrats in New Delhi are only abetting the growing sense of alienation and neglect.

A disarming proposal

Amartya Sen's tour of the Subcontinent after being awarded the 1998 Nobel Prize for Economics looked like a victory tour of a cricketing hero. Amidst the adulation, he had a brief chat with Himal's Beena Sarwar in New Delhi about India-Pakistan relations. Some salient Sen-isms:

No other country has as strong an interest in the continuation of civil democracy in Pakistan as India does. By conducting unnecessary nuclear tests, India has weakened the civil government and strengthened the military in Pakistan.

There is a very strong economic case for both India and Pakistan to disarm. There is a massive wastage oj military expenditure, nuclear and otherwise. As Mahbub ul Haq pointed out in one oj his reports, 85 percent oj the armaments purchased in the world market are sold by the jive permanent members ojthc Security Council. So it's not surprising that the Security Council does nothing to curb the amis trade. Meanwhile, what India and Pakistan lose because oj this is monumental, in terms oj human development and quality of life.

Nothing is as important as a dialogue with Pakistan. India and Pakistan can do less on their own than together.

It is important jor the international community to be sensitive to India's wo?ries about China, just as it is important jor the Indian public to be concerned about, and take note oj, Pakistan's legitimate worries about India. No thinking about security can be sensibly pursued without taking both these concerns into account.

The nuclear tests were a big moral mistake and added vastly to subcontinental tensions. India was very keen to keep Kashmir ojjthe international agenda—which would have been hard to do anyway, but since Kashmir is the major bone oj contention between India and Pakistan, the threat oj nuclear war makes it natural jor other countries to take an interest in this.

By testing, India has traded its military advantage over Pakistan in conventional warjare jor a nuclear stalemate. In a nuclear war there are no winners and losers. Ij India wins, but Delhi, Bombay, Madras and Calcutta suffer a nuclear holocaust, that's not a victory.