Kiran Kumari had been sick for more than a week. Now, lying on her back in a sweltering, overcrowded hospital ward, the skinny 11-year-old with the copper-streaked hair had lapsed into unconsciousness and could no longer breathe on her own. So her father was breathing for her.
Sitting on the edge of her thin mattress, his face a taut mask of exhaustion, the destitute farmworker rhythmically squeezed a football-sized plastic ventilator with his callused hands, forcing air into her lungs with every pump.
Such life-saving duties are normally left to professionals, but in this case, there were not enough to go around. Over the last two months, hospitals in the northern Indian state of Uttar Pradesh have been overwhelmed by Japanese encephalitis, a viral infection that has sickened more than 2,000 children and killed nearly 600, making it one of the deadliest outbreaks of the disease on record in India.
In this city at the heart of the epidemic, the main government hospital resembles a war zone, with desperately ill children crowded two or even three to a bed, family members camped in filthy corridors, and weary medical staff struggling to keep pace with about 30 new cases a day. Japanese encephalitis kills nearly 30 percent of its victims, mostly children younger than 15, and leaves many of the rest with permanent neurological damage.
The toll is all the more heartbreaking because the disease can be prevented by several vaccines, including one made in India and another, more effective version developed in the 1970s in China, where mass vaccinations have largely contained the virus.
In that regard, the latest outbreak shows how bureaucratic inertia, skewed priorities and what some health experts say is a nationalistic aversion to importing medicines are undercutting efforts to improve India's shaky public health system, to the detriment of its poorest citizens.
Last week in its annual human development report, the United Nations faulted India for falling behind on key public health goals, noting that its infant mortality rate is now higher than that of Bangladesh. One in 11 Indian children dies before the age of 5.
"It's a lot of politics in vaccine," complained Komal Prasad Kushwaha, a senior pediatrician at the hospital who has watched in frustration as the death toll from Japanese encephalitis in India has climbed steadily over the last two decades. "We have been crying for vaccine since very long. If vaccine is available for all children in the community, Japanese encephalitis will certainly be controlled."
Health officials in Uttar Pradesh have said they are trying to contain the epidemic by spraying against mosquitoes, which typically acquire the virus from pigs before passing it on to humans. Over the longer term, they are trying to shift pig farms, which can act as reservoirs for the disease, away from crowded villages.
The Indian health minister, Anbumani Ramadoss, has said he wants to remove barriers to the import of Japanese encephalitis vaccines in time to begin mass vaccinations in high-risk areas by April, before the disease makes its seasonal reappearance. Ramadoss and his aides did not respond to phone messages and two faxed requests for comment.
Japanese encephalitis occurs across wide areas in Asia, where about 50,000 cases -- and 15,000 deaths -- are reported annually, according to the World Health Organization, although the number of cases is thought to be vastly underreported. In India, the virus is concentrated in eastern Uttar Pradesh, the country's most populous state and one of its poorest, as well as the states of Andhra Pradesh and Assam.
In some respects, India should be well-equipped to contain the threat. Its cutting-edge pharmaceutical industry supplies life-saving medicines -- including measles vaccine and anti-retroviral drugs used to fight AIDS -- to much of the developing world; a government research institute has made a Japanese encephalitis vaccine for years.
But the Indian vaccine is expensive, time-consuming to produce and relatively short-lived in its effectiveness. Because the government has resisted importing better versions from China and elsewhere, or licensing their production at home, India has adopted what Julie Jacobson, a virologist, calls a "firefighting approach" to Japanese encephalitis, ramping up domestic vaccine production in response to each outbreak, by which time it is often too late.
"It's just amazing that with that kind of technical capability, the problem of Japanese encephalitis has not been solved" in India, Jacobson said in a telephone interview from Seattle, where she directs a $27 million Japanese encephalitis initiative for the Program for Appropriate Technology in Health, a nongovernmental group. The effort is funded by the Bill & Melinda Gates Foundation.
"It hasn't been a high enough priority," added Jacobson, although she described the 15-month-old government of Prime Minister Manmohan Singh as "very interested in moving forward right now and solving this problem."
The human costs of the latest outbreak are all too evident in Gorakhpur, a city of about 300,000 roughly 400 miles east of New Delhi, the capital, on the swampy sub-Himalayan plain near the border with Nepal. Since late July, the epidemic has been raging in the poor farming villages that surround the city, where the public BRD Medical College hospital has treated the majority of the underage victims.
Because there is no cure for the disease, medical staff members can try only to ease its symptoms, providing drugs to treat fevers and convulsions or inserting feeding tubes when children become unconscious. A grimy four-story structure whose grounds are covered in weeds and trash, the hospital is treating about 230 encephalitis patients in three wards with a bed capacity of 180, according to Kushwaha, the senior pediatrician.
Children at the hospital are dying at the rate of about one every two hours, and doctors and nurses are in such short supply that in many cases parents are the only ones keeping their unconscious children alive, using foot-operated suction pumps, for example, to clear airways of mucus and saliva. But the mostly illiterate villagers are not always up to the task. More than half of the deaths in the encephalitis wards are caused by aspiration choking, which occurs when the internal airway is blocked, according to Bhupendra Sharma, a senior resident physician.
The sickest patients are in Ward 6. On Wednesday night, mothers in colorful saris and fathers in simple work clothes clustered around their mostly inert children, sometimes sponging their feverish bodies with damp cloths. A few dozed on straw mats unrolled beneath iron-framed beds. Some children breathed through oxygen masks.
Kiran Kumari, the 11-year-old, lived with her parents and six siblings in a mud-and-straw hut about 40 miles from Gorakhpur. After she began having seizures, her parents and teenage sister brought her to the hospital last Sunday in a motorized rickshaw. A few days later, when the girl became unconscious, medical staff members inserted a plastic tube in her airway and showed her family how to use the hand-operated ventilator, as the mechanical ones were all taken.
"For four days, we haven't been able to eat or cook any food," said Kumari's mother, Gulaicha Devi, 40, a slight, careworn woman with a prominent gold nose stud and glass bangles on both wrists. "We're so tired. We didn't bring anything with us. Not a glass of water to drink from. Not a change of clothes."
Despite their exhaustion, Kumari's parents and sister kept substituting for each other on the ventilator, refusing to give up hope. It was no use. On Thursday morning, they and their daughter were nowhere to be found, and another sick child had taken her bed.
A doctor said the girl had died at 5:15 a.m.