For decades, with unflinching regularity, death has arrived at Gorakhpur. Lives are lost as doctors try their utmost. But, what is it about the city and the areas around it that makes it so susceptible to outbreaks of Acute Encephalitis Syndrome (AES) and Japanese Encephalitis (JE)?
Some argue that it is, at least partly, due to politics and an unfair emphasis on Gorakhpur. Dr RN Singh, an expert on AES and JE, was the first doctor to come across a case of JE/AES in 1978 during its first outbreak, who asks, “Why focus only on Gorakhpur, when other states have cases too? Sometimes more?" A self-confessed supporter of the Yogi Adityanath-led government, he adds, “It is all politics".
The numbers, at first glance, do seem to support him: more than half the cases of AES and JE till September 2018 were reported in Assam, with Uttar Pradesh accounting for less than a fifth of the total cases in the country, as per the National Vector Borne Disease Control Programme (NVBDCP). But between 2007 and 2016, nearly 75,000 cases were reported from 22 states and union territories in India with a fatality ratio of 15%. Of these 44% were from Uttar Pradesh - mostly from Gorakhpur and its adjoining districts.
It isn’t just lack of awareness or the crumbling health care infrastructure which is ubiquitous across the state that has allowed the disease to proliferate - but also specific factors unique to the area that have been exacerbated due to climate change.
Climate change and mosquitoes
India has four states where JE is endemic - Uttar Pradesh, Assam, West Bengal and Assam. While all of these states have for decades looked at attempting to stop the disease through the narrow prism of increasing the number of beds in hospitals and providing medicines, the climate of Gorakhpur (and adjoining Siddharthnagar, Kushinagar and Maharajganj) makes it particularly vulnerable to the disease.
While temperatures range from 8.9 degrees Celsius to 38.3 degrees Celsius - the bulk of the cases were reported between July and November, with cases peaking after October. With an average of 52 days of rain between June and August in a year, a relative humidity of 50-55% and temperatures ranging around 28 degree Celsius - researchers found that Gorakhpur has the ideal climate for mosquitoes breeding.
A 2007 study by the scientists at the Institute of Preventive Medicine, National Taiwan University argued that both temperature and precipitation had been associated with the density of mosquitoes “and are also highly related to occurrence of JE". With climate change leading to variable rain and warmed temperatures, researchers feared that climate change could trigger an increase in cases of JE.
More recently, a 2017 study by The New York Center for Travel and Tropical Medicine said that global climate change and resulting temperature changes could lead to a change in the “peak and duration of transmission season".
Climate change and floods
Cases in the past years haven’t been restricted to the rural areas and have, in fact, been concentrated around the bowl-shaped Gorakhpur city with its high groundwater table. The gradient inevitably leads to problems of water logging that creates ample space for JE vector mosquitoes to breed and thrive. But in the past decade, the area has also seen a number of flash floods due to climate change.
A 2013 study by the National Institute of Disaster Management noted that although the area is “chronically flood prone", the “very nature of flooding is changing due to climatic conditions, with greater intensity of flash floods". It said that embankments along rivers were unable to withstand the flooding and would often break and the resulting water logged situation would lead to “Many people becoming victims of the water borne diseases like diarrhea, cholera, dengue, JE, as the flood waters stagnate and the natural lines of drainage are disrupted due to construction of embankments, roads and other encroachments."
A 2009 study by the Department of Public Health and Epidemiology, Swiss Tropical Institute noted that “generally extreme rainfall after a period of drought can trigger outbreaks in situations wherein vector populations rapidly proliferate and blood feeding is spilling over to humans."
Irrigated rice agriculture
A 2005 study by the Swiss Tropical Institute looked at the relation between rice agriculture and clinical parameters and found that of the 1.9 billion people living in JE-prone areas of the world, 220 people lived in proximity to rice-irrigation schemes. The spread of JE in these countries coincided with a 134% increase in rice production globally, from 226 million tonnes to 529 million tonnes.
Another study in 2009 by the institute pointed that the JE virus was mainly transmitted by the mosquito Culex tritaeniorrhynchus “which prefers to breed in irrigated rice paddies" and noted that “where rice production and pig rearing overlap, the impact on JE transmission is stronger than in areas where both activities are physically separated." Infected pigs act as amplifying hosts for the disease.
As Gorakhpur developed, so did an intensive network of canals for irrigation in the past five decades. This construction of unlined canals resulted in the ground table increasing even further and resulting in more floods and stagnant water, following floods. This impacted livelihoods, with the area cultivated in Kharif, falling drastically from 214,000 hectares to just 68,000 hectares due to regular floods.
For farmers, as grazing land disappeared, there was only one choice - switching from large bovines such as buffaloes to pigs. “The tradition of animal husbandry too has been undergoing changes due to water logging; as grazing lands remain submerged in water for long periods, large bovines have declined in population. Marginal farmers and landless have increasingly taken to piggery. All these factors contributes to increase of JE incidence in the eastern districts during the past decades," noted the National Centre for Disease Control in a 2012 review published in the WHO South East Asia Journal of Public Health.
(This story is part of a News18 series probing the encephalitis menace that hits Gorakhpur every year)
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