1. SUMMARY: September 6-7, ConGen visited the East Indian
state of Bihar to assess its public health issues. Bihar,
India's poorest state, presently has 19 polio infections this
year, second only to its neighbor Uttar Pradesh (UP), which has
291 cases as of September 25. Local officials with the United
Nations Children's Fund (UNICEF) office and an NGO working in
public health believed that the recently-elected state
government was making a strong effort to control the polio
infections in Bihar. However, many years of bad governance and
a weak public health infrastructure complicate efforts to reach
remote rural areas. As a result, the state also experiences
high rates of child mortality: approximately 400 children die
every day in the state, 60 percent just in the first month after
birth. In addition, UNICEF officials described the state as a
"black hole" for accurate information on HIV/AIDS infection
among its sizable migrant population. If the persistence of
polio in the region is an indicator, the local medical
infrastructure will likely be unable to deal with other emergent
infectious diseases such as the growing HIV/AIDS infections, and
opportunistic diseases like tuberculosis. END SUMMARY.





2. Bihar suffers from great poverty. According to World Bank
figures, 47 percent of its 83 million people earn less than USD
12 a month. The state struggles to provide rudimentary health
care services and experiences a range of serious public health
problems. As of September 25, Bihar has had 19 new polio
infections, which is a relative improvement over last year's
infection numbers. During the same period the previous year,
Bihar had 30 cases. However, India as a whole has seen an
explosion of polio, with presently 326 new cases, as compared to
last year's country-wide total of just 66 cases. UNICEF State
Representative Bijaya Rajbhandari commented that the improvement
in this year's infection rates for Bihar can be attributed to
greater effort by state Chief Minister Nitish Kumar, who was
recently elected in November 2005. Kumar has pressured health
officials to implement more effectively the pulse polio
immunization. Kumar's first official public activity was in
fact a pulse polio immunization program and numerous billboards
around the state capital Patna showed Kumar giving oral polio
vaccine to a child held by a woman in a burqa. The billboards'
display of a Muslim woman and child demonstrated the state's
focus on the Muslim community, which has been resistant to
immunization. Rumors had spread among the community that the
immunization was an effort to sterilize or poison Muslim
children. Rajbhandari said that as part of the Muslim outreach,
Imams accompanied immunization teams to explain the importance
of the polio vaccine. Echoing UNICEF's comments, American
Warden and NGO director Rick Fendrick said that in the Bodh Gaya
regional hospital, more medical equipment and staff recently has
become available and medical service was improving. However,
the marginal improvements in Bihar's public health system cannot
correct years of poor governance and weak medical infrastructure.





3. In addition to polio, according to Rajbhandari, Bihar is a
"black hole" for statistics on HIV/AIDS infections. The lack of
an effective sentinel program in the state means that UNICEF and
other medical services do not have a clear sense of the
infection rates. Rajbhandari noted that the National Aids
Control Organization (NACO)'s sentinel program involves testing
of pregnant women. However, only about 12 percent of pregnant
women in Bihar receive professional medical care. Most women
give birth in remote villages and experience high child
mortality rates. Until last year, NACO reported a prevalence
rate of .13 percent for HIV/AIDS infections in the state.
However, two studies of surveys done by the Bihar State Aids
Control Society (BSACS) in 38 districts in July 2005 and
December 2005 found a dramatically increased prevalence rate of
.53 percent. Bihar has reportedly 8,128 people diagnosed HIV
positive and about 1,070 cases of AIDS. Earlier this year, A
senior BSCAS official was quoted by the Times News Network as
saying, "The rate at which infection is spreading, very soon, it
may cross the 1 percent prevalence rate." (REFTEL).

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4. Some districts have reported infection rates that
significantly exceed epidemic levels: Sitamarhi and East
Champaran have rates of 3.7 percent and 2.28 percent
respectively. In March 2006, Health Minister Rai told ConGen
that the infections are concentrated in areas that are a source
of migrant labor for the rest of India. According to the
Institute of Human Development, New Delhi's report "Rural Labor
Migration From Bihar," 48 percent of all Bihar households
reported at least one family member who was a short-term
migrant. Bihar appears to be developing into a reservoir and
potential source of future HIV/AIDS infections for India, just
as it has for polio.



5. Rick Fendrick, commenting on the HIV/AIDS situation in
Bihar's Bodh Gaya area, said that he was personally aware of
eight cases in that district. He knew of one case in which an
infected HIV/AIDS patient went to several doctors and facilities
in Bihar with symptoms of related, opportunistic diseases and no
doctor considered testing for HIV/AIDS. It was only when the
patient was in New Delhi that a test was done. Fendrick said
that the failure to test in Bihar reflected the continued lack
of even basic awareness about HIV/AIDS among medical personnel
in the state and that they were unable to recognize symptoms of
typical opportunistic diseases associated with HIV/AIDS. He
also noted that due to the relative high cost, Bihar authorities
were unable to provide therapies for drug-resistant HIV/AIDS
cases. Fendrick said he believed that drug resistant cases were
present in Bihar and he mentioned the case of one woman with
HIV/AIDS who was initially responsive to the anti-retroviral
drugs but then saw a rapid reduction in her white blood cells.
He also identified drug resistant tuberculosis as another
concern.





6. Comment: The persistent and growing problem of polio in
Uttar Pradesh, Bihar and neighboring states is symptomatic of
the poor governance and weak medical infrastructure in much of
Eastern India. The failure to address this disease does not
bode well for the prospect of controlling other infectious
diseases such as HIV/AIDS and tuberculosis in the region.
Already, epidemic levels of HIV/AIDS have developed in some
pockets in Bihar and because of the poor sentinel system in the
region, it is impossible to assess the full extent of the
HIV/AIDS infections.
JARDINE