Children with acute encephalitis syndrome undergo treatment at the Sri Krishna Medical College and Hospital in Muzaffarpur, Bihar. As of June 21,104 of the 424 children admitted since January 1 had died due to AES. | Photo Credit: Ranjeet Kumar
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Cases of acute encephalitis syndrome have seen a spike in Muzaffarpur this year, already claiming more than a hundred lives. Jacob Koshy reports on the appalling state of health care in Bihar, even as the debate on what is causing the deaths rages on
For three days, Bihari Mahato and Shyam Babu Saha’s families have shared a hospital bed. The two daily-wage labourers, who have had to give up work for three days, haven’t exchanged a word, though they have much in common. Both have a boy and a girl each. And their children are battling for life.
Sundar, Mahato’s three-and-a-half-year-old son, is naked, emaciated, delirious and has a distended stomach. Himanshi, six months old and in a striped shirt and shorts, looks bigger and healthier than Sundar. She sleeps longer — fitfully, her mother Vimla says. Both families are from different districts of Bihar. Mahato is from Muzaffarpur and Saha is from Sitamarhi district. Their children were suddenly taken ill. When the children were convulsing and feverish, they were rushed to the Sri Krishna Medical College and Hospital (SKMCH) in Muzaffarpur. The doctors noted that their blood sugar had dropped precipitously.
Both children are being given dextrose saline (a sugar solution often administered intravenously), but their parents are nervous. “The fever has subsided but it keeps returning,” says Saha. “The doctors aren’t paying us much attention.” But that’s a quibble given that many other ailing children are sprawled out on mattresses on the floor. Amidst peeling plaster, strewn banana peels, stomping doctors, nurses, journalists and television crew, the children’s ward at SKMCH is symptomatic of the confusion and panic that has gripped Muzaffarpur since early June.
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Parents of Dileep Kumar, who died in SKMCH,in front of their home in Manika Bishunpur Chand village, Muzaffarpur. | Photo Credit: Ranjeet Kumar
The floor above the general ward is home to the Intensive Care Units (ICUs). Each of the five ICUs has eight beds. Not one of the beds has fewer than three children hooked to bleeping monitors and intravenous lines. Unusually for an ICU, there’s little restriction on non-hospital staff shuttling in and out, but unlike the squalid paediatric wards below, there are no patients sprawled on the floor. The floor is clean, the air-conditioners work, the nurses are extra vigilant, and yet here’s where death lurks around the corner.
Season of trouble
There is a protocol for doctors. As soon as children are wheeled in, they are monitored for fever, convulsions and signs of confusion or loss of consciousness. “What I’ve seen is that several children are brought too late. Unfortunately we lose them,” says J.P. Mandal, a resident doctor at SKMCH. Between June 1 and 17, 312 children were admitted to the hospital under the umbrella diagnosis of acute encephalitis syndrome (AES). According to the Bihar health department, 85 died. The bulk of the dead, 48, were children aged three to seven. Twenty-nine children were less than three years of age. As of June 21, 104 of the 424 children admitted since January 1 had died. Encephalitis, which refers to an inflammation in the brain due to a viral or bacterial attack, causes fever and almost never a drop in blood sugar. In the current epidemic, as well as in previous ones in Muzaffarpur, the doctors have marked cases of and deaths by hypoglycaemia (drop in blood sugar), which is unusual.
While Bihar loses hundreds of children to AES every year, there were sharp spikes in 2012 and 2014, when 395 and 372 children, respectively, lost their lives. Through the years, AES cases have been reported from several districts in Bihar: Gaya, Patna, Aurangabad, Saran, East Champaran, Sitamarhi and Vaishali. Government figures show that the peak years of 2012 and 2014 saw Muzaffarpur account for 35-40% of hospital admissions. While this year’s incidences and deaths are fewer in comparison, the season of trouble is far from over. The outbreak in 2012 took place between May and November. In 2014, it was from May to July. There’s no saying how long the current outbreak will last. A common refrain among district administration officials and some doctors is that the yearly outbreak ceases in intensity soon after the monsoon rains begin in Bihar. Why is that? Nobody ventures an explanation.
Sanjay Kumar, the State’s top civil servant in charge of health, says he cannot quite put a finger on a “single, determining factor” that is responsible for 2019 turning out to be a bad year. It could be the ongoing heatwave — several parts of Patna, Gaya and even Muzaffarpur have recorded temperatures in excess of 4-5°C over what’s normal for this time of the year. At least 80 people have succumbed to the heatwave. “The added heat and humidity could have made young children particularly susceptible to dehydration,” he reckons. “It could also be an infectious disease. It could also be because of children eating litchis.”
Kumar says all the children who are admitted belong to the lowest socio-economic rung; there are no instances of infection in cities or even semi-urban localities. He emphasises that the government had been prepared this year too, like in the past, for the outbreak. It stocked up and supplied oral rehydration solution, ensured that medicine and equipment were provided at medical colleges and district health centres, and conducted public awareness campaigns about the imminent outbreak. However, he admits that the district’s key referral hospital, SKMCH, wasn’t equipped to deal with the deluge of patients. “This year will be a turning point. The bed capacity will be increased to 1,500 and we will have a virology lab [to better investigate vitals of patients and determine disease causes].”
Debating the litchi link
Arun Shah, a paediatrician and private practitioner who has been working in the city since 1984, insists that the spike in AES cases and in fatalities is a result of malnourished children suffering brain damage after eating litchis, particularly unripe or overripe ones. In a 2014 paper, Shah and virologist T. Jacob John had argued that the children in Shah’s clinic in Muzaffarpur were found to have extremely low blood sugar levels and signs of brain damage. While viral or bacterial infections that cause encephalitis (an inflammation of brain cells due to an infection) were well known in Muzaffarpur and neighbouring districts, many of them were taking sick and dying due to encephalopathy (brain damage, in this case, due to an environmental toxin). In 2016, a detailed investigation, published in The Lancet Global Health by the National Centre for Disease Control, India, and the U.S. Centers for Disease Control and Prevention, found “confirmation” that litchis contained a chemical called methylene cyclopropyl glycine (MCPG). These are naturally occurring toxins that cause hypoglycaemia and metabolic derangement in children.
When a child is malnourished, her body, having exhausted its reserves of glucose from the digestive tract and the liver, typically turns to fatty acids in biochemical desperation to supply blood sugar to the brain. MCPG, the theory goes, thwarts this mechanism. This can send the brain into hypoglycaemic shock triggering convulsions and, if unaddressed, even death. “But please don’t blame litchis,” stresses Shah. “It is the pride of Muzaffarpur.”
At a press conference two years ago, to underline that the litchi fruit was only a triggering factor and sickened only malnourished children, Shah and John ate a bowlful of the fruit in front of television cameras to emphasise that it was malnutrition, and not the fruit, that was the dominant cause of the disease. Shah is unambiguous that the children are suffering because the government didn’t do enough. The recently concluded Lok Sabha election distracted the government from adequately preparing for the outbreak, he says. In 2016, he was part of a government-constituted committee that prescribed guidelines: Children shouldn’t be allowed to skip their evening meal, they should avoid stepping out in the heat, and local public healthcare centres must stock up on anti-convulsion drugs as well as dextrose. These were adhered to in 2017 and 2018. And that’s why there were relatively fewer reports of AES, he argues.
While encephalitis outbreaks in Uttar Pradesh’s Gorakhpur were due to other causes, and children from Muzaffarpur and neighbouring districts have battled viruses such as the Japanese encephalitis virus, the large-scale litchi cultivation in Muzaffarpur, which contributes about 40% of the State’s litchi production, “can’t be ignored as a triggering factor,” he points out.
At SKMCH, several parents of the ailing children are categorical that their children did not eat litchis. The authors of The Lancet study found that two-thirds of children who were sick had eaten litchis. “We work in the fields and there are litchi orchards aplenty where we live,” says Indal Paswan, whose two-and-a-half-year-old son is prostrate on a hospital bed. “But this boy isn’t capable of plucking fruit on his own. We do feed him some fruit as well as other food but we don’t starve him.”
Mandal is insistent that there is a virus or some biological agent that is responsible for the recurrent outbreaks. He scoffs at suggestions of the litchi’s complicity. Children who were brought to the hospital were “poor but not classically malnourished,” he says. If malnutrition and litchi consumption were the causes, then there ought to have been a fairly constant number of deaths every year. This has not been observed, he says. “A peak and an ebb in cases and deaths is what we see. And that’s more typical of a biological agent.”
Ground Zero For Life
That no virus or bacteria has been isolated yet in Muzaffarpur is because the hospital lacks adequate facilities to collect tissue and blood samples from patients and preserve them adequately for examination. “I’m confident that at some point this will be found and there will be no mystery,” Mandal says. The focus of treatment, he adds, is to ensure that convulsions are brought under control and blood sugar levels are restored.
What Shah and Mandal do agree on is that the vast majority of deaths could have been prevented if the children had made it to a hospital on time. The most important medicines were easily available, and most of the primary health care centres were well stocked and equipped to deal with AES cases.
No time to grieve
Yet, four-year-old Mohammed Jahid lost his life. Until he fell sick, Jahid had spent his days playing with his older siblings and cousins in the village of Bishnupur Chand, Musahari. His home was a single room thatched hut that did not have a toilet. His and his cousins’ houses lay at the edge of an orchard that had several rows of tall, stout litchi trees. In June, there were only a few fruits that clung to the trees. Most had been plucked and carted away for sale by the owner of the orchard who lives in Patna. “He didn’t show any signs of illness. He had a fever for two days,” recounts Jahid’s aunt, Asha Khatoon. “We took him to a private doctor nearby.” One night, Jahid became delirious, and his father Mohammed Idris rushed to get an autorickshaw to take him to a hospital. He didn’t find one immediately as the roads had been dug up. When they made it to SKMCH, Jahid was immediately taken to the ICU, but he didn’t survive beyond three hours. A day after burying Jahid, Idris was away to find work as a daily-wage labourer. There were still two boys, two girls and a wife to feed.
Dinesh Ram, who lives half a kilometre away from Jahid’s house, mourns the loss of his three-year-old son, Dileep Kumar. The boy had complained of stomach pain for three days and the local doctor had prescribed a tonic. That didn’t work. When the child turned febrile, Ram scrambled to get him to SKMCH that was about 20 km away.
The Bihar government has announced ₹4 lakh as compensation to every family that has lost a child to AES. Ram didn’t know that. He was unaware that he had to collect a death certificate from the hospital to claim the compensation. He’d thrown away the medical receipt after he had his son cremated. “We are poor and unaware. I really don’t know what to do. There are other children to take care of,” he says.
Poor health record
Irrespective of whether a biological agent or malnutrition is to blame, Bihar’s poor track record in ensuring that the poorest have access to adequate nutrition and distrust in the public health care system are major causes for the deaths. “SKMCH is a tertiary care centre and is a medical college-cum-hospital. We have our limitations. Encephalitis is not the only thing we deal with. Several primary health centres are well equipped and well staffed, but people somehow believe that they can only be saved here,” says Mandal. “There are clear state-directed guidelines on what signs and symptoms doctors have to watch out for, and there is a clear action plan. Just following it is adequate.”
A senior government official, who doesn’t want to be identified, says doctors in several primary health care centres are “afraid” of doing anything beyond the bare minimum to rescue a child. “Because the primary health care centres and health centres are located in a village or community, there’s a greater chance of violence in case a child dies. Over the years, this has led to a lack of trust among people in their nearest health facility and they opt for tertiary care. Solving this remains among the government’s key worries,” he says.
Moreover, Bihar’s position at the bottom of national health indices makes novel diseases harder to detect and known diseases harder to treat. According to the National Family Health Survey (NFHS) of 2015-2016, 48% of children in Bihar were stunted, compared to the national average of 38%. Bihar also performed poorly in terms of its ability to spend and implement schemes that provided nutritious food to children and expectant mothers. Two-thirds of eligible children did not get healthy meals, the NHFS report noted.
Shah says he’s decided to embark on an experiment to conclusively prove that malnutrition is the single biggest cause of Muzaffarpur’s tragedy. Along with a team, he will be identifying villages in blocks that show maximum mortality. He says before the litchi season next year, he will personally ensure that children are well fed and that they don’t eat too many litchis or loiter about in the heat. “I promise you there will be zero deaths. Then perhaps the State administration can become more serious about addressing hunger and malnutrition,” he says.
But today, the State has failed Muzaffarpur’s children.
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Ground Zero For Life Clyde Lewis
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Ground Zero shines a light on the dark corners of reality ! He could be kidding, then again, he couldn't be more serious. Ground Zero goes where the mainstream media is too afraid (or stupid?) to go! ..
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http://www.groundzeromedia.org/
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The site where the World Trade Center's twin towers fell in the Sept. 11, 2001, terrorist attacks, in Manhattan, New York / AP
BY:
There have now been 15 September 11ths since the one we call simply 9/11, that day when the Twin Towers of New York’s World Trade Center were hit by airplanes being used as missiles and crashed to the ground, killing almost 3,000 people. We call the site 'ground zero,' which started as the military designation for the place where a nuclear bomb detonates, its effects spreading out for hundreds of miles. Now the phrase is so associated with this epoch-changing event and place, people may assume that’s just what it means. And while there was no literal blast spreading far beyond the towers, certainly there were far-reaching effects: 9/11 initiated a new era in American military intervention and the frustratingly dangerous and out-of-kilter world we live in.
But that’s not the subject of Lynne B. Sagalyn’s door-stopper of a book (900 large, small-print pages) about why this piece of real estate looks the way it does 15 years after 'the' 9/11. Refreshingly, it’s about what it says it’s about: Power at Ground Zero: Politics, Money, and the Remaking of Lower Manhattan. Sagalyn is a professor emerita of real estate at Columbia Business School, and the book is the back story to what you see when you walk around this multi-purpose site now. Buildings, empty space, memorials, lines of people, a museum, a sky-scraper, a transportation hub, and soon to be a performing arts center: how did it all get to be the way it is? Which of the major players eager to put his mark on so important a site won which battles?
It’s a juicy story, Batman vs. Superman vs. Ironman, a real clash of titans, New York-sized egos. The biggest rivalry was political, a fight for power between New York’s Mayor Michael Bloomberg and the New York Gov. George Pataki. Bloomberg won repeated victories. Another victor was developer Larry Silverstein, battling the Port Authority of New York and New Jersey, which owned the site, with a constant can-do attitude and a refusal to be beaten out of control of this central piece of land. Artistic spats provided the intellectual conflict. What, if anything, remains of Daniel Libeskind’s initial design? Who got the contract for the central transportation center and how does it look? Why are the fountains the way they are?
All the arts have their practical side, and architecture is the most practical of all the arts. It is also part of the larger fabric of urban design, where the art meets the sidewalk, a combination of ideology, engineering, and aesthetics. And it all seems the ultimate expression of power: a creation of a whole world, rather than just something we put on a shelf or hang on the wall. At least since Ayn Rand’s Frank Lloyd Wrightesque architect hero Roark in The Fountainhead, the idea of being able to actually change the things people live in has seemed to express the greatest power over mankind. If I write a book, you don’t have to read it. But if, like Santiago Calatrava, you got the contract to design the place where my PATH train from Newark, N.J., pulls in, I have no choice but to be in your building.
As I learned on a recent trip, the sensation of arriving via the PATH from Harrison, N.J., and ascending into the 'Oculus' is like finding yourself, like Jonah or Pinocchio, in the belly of a whale. You’re in Calatrava’s 'transit center' that I read is supposed to look from the outside like (oy vey, as New Yorkers say) hands releasing a dove. Only it doesn’t look like hands releasing a dove; it looks like what’s left of the Thanksgiving turkey carcass after a particularly hearty repast. But be warned: it’s not just a train station. You’re not meant just to use it; you’re supposed to 'get' it. The good news is that no points are taken off if you just shrug and move on to see what else there is to see.
The idea of having a building look like an object has a long tradition of tacky American adherents: all those donut shacks shaped like giant donuts off the Interstate in the Midwest that began to disappear as McDonalds and the arches appeared, and cities filled up with towering steel and glass right angles. But everything old becomes new, which is why I’m glad I never threw away the skinny knit ties from the 60s I almost discarded decades ago. With Frank Lloyd Wright’s Guggenheim, a building without square corners—and annoying as an art museum since you’re always inching up or down the ramp—we entered the period of our current high art appropriation of 'shape' buildings. The most famous proponent nowadays of buildings as cool objects is of course Frank Gehry, who believes in waves where everybody else expects things to be flat. These blobby anything-but-right-angled buildings always look best on a selfie, seen from without and far away.
I admit that when I visited the whale, it didn’t yet have its mall, which will be the reason many people go into this building. So much for hallowed ground, or the clash of great egos: a mall is a mall, whether at Ground Zero or in Annapolis, my home, where the same company (Westfield—actually an Australian company) runs an essentially identical one. Sagalyn’s book points out that Westfield had contracted to build a mall in the old World Trade Center before it was destroyed, and exercised its option to return.
When I went outside, the building got literal and read 'World Trade Center,' and of course I took pictures. I wanted to get free tickets at the Museum, but it turned out these were only available for an hour, and the line was endless. So I went to look at the memorial voids instead, before getting an ice cream.
Yes, those fountains. Pretty scary, and very deep. (Is that part of the experience, our faint feeling of threat?) Since Maya Lin’s Vietnam Veterans’ Wall in Washington, the trend in memorials has been negativity: what’s not there. The idea was perhaps created by Edwin Lutyens, perhaps best known for the Indian government center of New Delhi, but also for the Cenotaph in Whitehall: it’s the absence of a tomb that’s striking. Of course, not everybody likes these intellectual anti-memorials, like people who prefer generals on horses. Protest by Vietnam veterans led to the construction of what sophisticates see as tacky realistic sculptures of soldiers nearby the Wall.
At Ground Zero, there are no realistic sculptures. Just Michael Arad’s holes in the ground, vast black square drain holes for water that falls rather than shooting up, located where the twin towers were located. If you didn’t know why they look the way they do, and why they are so big, and why they are here, you wouldn’t know. It’s conceptual. And the so-called 'Freedom Tower' is similarly symbolic, purposely made to be 1776 feet high, though in fact a rather forlorn single skyscraper looking a little out of place.
As an ensemble, it makes no sense, and we have to have it explained to us—as Sagalyn does. In this it’s like much contemporary art, which is about the concept, not the object. Knowing about the political wrangles for power that produced this jumble of competing ideas makes it cohere, sort of. Oh, so that’s why it’s this way! And the whole thing certainly has re-made lower Manhattan, to go back to Sagalyn’s title. Now tourists come, and the Wall Street area is alive after hours, and many drift south to pleasant Battery Park, alive with families and vendors and ferries to the Statue of Liberty.
It may turn out that a mall just north of Battery Park and the Wall Street Bull is just what Manhattan needed. Now people come to gawk, and pay homage, to rest their feet or to shop. Or to buy an ice cream. It’s a famous site, whatever structures are erected or not, whether fountains shoot water up or let it fall down, whether or not the train station looks like a turkey carcass or hands. Now the titans are silent, their battles over. Sagalyn brings them briefly to life, but then we close the book. Where do we get the PATH train back to Harrison?
Life goes on. This is what 9/11 teaches us. And this book as well.
Sep 18, 2013 Cause at the end of the book there’s a map picture for Infinity Blade 3, but so far I haven’t seen it the game. The picture shows one of the heads on either the left or the right side of the middle building in the hideout. I’ve just been wondering about it for a while now. The Map to Heaven is a map that is obtained by defeating Lelindre with Siris. It does not yield an item, instead it reveals a secret part of the Metius Observatory. Along with the Map to Heaven, you need to acquire the Blade of Heaven and the Axe of Heaven, and equip them to access the hidden. Map to heaven infinity blade 3. Infinity Blade III (3) Treasure Map Guide, Help and Walkthrough By: Chair Entertainment Group, LLC. See all our Infinity Blade guides in one handy place.See our Ausar Rising guide here. Here you’ll be able to find the locations for the treasure maps in Infinity Blade 3. Sep 04, 2014 The highly anticipated Infinity Blade III ‘Kingdom Come’ update is now available in the App Store. This is not only the final content update for the popular game, but ChAIR says that it includes everything needed to bring the entire Infinity Blade trilogy to an end. Map to Heaven. Classic editor History Comments (4) Share 'Return the blade and accept death as your reward!' This page is a candidate for deletion. Policy. Appeal. What Links Here. Page History. Infinity Blade Wiki is a FANDOM Games Community. View Mobile Site.
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