The death of around 200 children in the state of Bihar has attracted national attention to the cycle of tragedy that is Acute Encephalitis Syndrome (AES), also known as brain fever or chamki fever.
Encephalitis is an inflammation of the brain caused either by an infection invading the brain (infectious encephalitis) or through the immune system attacking the brain in error (post-infectious or autoimmune encephalitis).
According to the U.K.-based Encephalitis Society, over 5,00,000 people are affected by encephalitis globally each year, however 78 percent of people across the world lack a basic understanding about the condition.
Characterized by acute seizure and mental disorientation, this unexplained neurological illness affects the central nervous system.
Muzaffarpur in Bihar is one of the largest litchi-cultivating regions in the country and over 150 deaths have been reported in that belt alone in the past one month. The outbreak is distinctly seasonal and begins around mid-May and peaks in June, which are the months of litchi harvesting season.
A study titled “Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study” by the Lancet attempted to study the cause and risk factor of this illness.
The study found that between May 26 and July 17, 2014, approximately 390 patients with suspected litchi-induced illness were admitted to the two Muzaffarpur hospitals considered in the case study. Out of the 390, 122 (31 percent) had died.
A toxin called methylenecyclopropylglycine (MCPG, also known as hypoglycin A) naturally present in litchi is said to be responsible for the deaths. Overnight, this toxin causes the blood glucose level in under-nourished children to fall considerably, leading to severe brain malfunction. The research pointed out that these grave changes were not seen in well-nourished children. It is important that we note the toxin acted up only in children who were not well-nourished. That is to say, the problem lies not in the fruit, but in the dietary habits (and by extension economic means).
If the toxin in litchis was responsible for the epidemic, then the effect would have been uniform in all socio-economic groups. However, in this case, only children of the lower income groups have been affected.
On June 25, 2019, India Today carried out an interview with the National Research Centre on Litchi Director Dr. Vishal Nath, who refuted claims that consumption of the fruit could have caused the deaths. “Litchis have nothing to do with encephalitis. There are no toxins in the edible part of litchi. It is very unfortunate that people have been misled about the fruit. From Muzaffarpur, this fruit gets transported to big cities including Mumbai and Delhi. It is being consumed across the country. Then, why did encephalitis not break out in other parts of the country?” he asks.
These are reasons enough to believe that the problem stretches beyond the purported link to litchi. The actual problem(s) causing these tragic deaths run deeper than what the state machinery would want any of us to dwell on. The issues at play here range from malnutrition and poverty to lack of proper healthcare.
Our efforts to understand the encephalitis deaths in Bihar must begin by understanding the existence of different kinds of India. The country is home to more than 1.2 billion people residing in a variety of geographies and characterized by diverse cultural, ethnic, linguistic and religious affiliations. India’s economy has grown rapidly in the past few decades, however well-being and prosperity (and the yardstick by which they are measured) vary widely across the country.
Data suggests that in the past few years millions have been lifted out of poverty, but progress is not uniform throughout. While some states have seen appreciable progress, others continue to struggle under the burden of crippling poverty. One of these low-income states is Bihar.
In the 1980s, demographer Ashish Bose coined the acronym BIMARU (meaning laggard in Hindi) to refer to the adverse social and economic conditions in the states of Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. Over the years, news reports have suggested these states have made considerable progress. In 2015, during the campaign trail for Bihar’s legislative assembly election, when Prime Minister Narendra Modi said he would remove the Bimaru tag if given the mandate, the state’s Chief Minister Nitish Kumar said it had long left behind that tag.
“He [Modi] said Bihar is a Bimaru state. Bihar's growth rate, performance on social indices like education and health care present a picture which does not show it is a laggard state. He should have his facts right. Nobody will like to make a joke of himself by calling Bihar a BIMARU state,” Kumar said hours after Modi promised to remove the tag by ushering in development once National Democratic Alliance (NDA) was voted to power in the state.
However, numbers suggest otherwise. According to the Multidimensional Poverty Index (MPI), created by the Oxford Poverty and Human Development Initiative, Bihar remained India’s multidimensionally poorest state from 1998-99 to 2015-16. The MPI goes beyond income to assess how people experience poverty in simultaneous and multiple ways. It identifies how people are being left behind across three key dimensions: health, education and living standards, and 10 indicators – nutrition, child mortality, years of schooling, school attendance, sanitation, cooking fuel, drinking water, electricity, housing and assets.
The MPI further found that between Bihar and Uttar Pradesh there were over 320 million multidimensionally poor people and nearly 50 percent of Bihar’s population fell in that category. To put the numbers in perspective, just one percent of Kerala’s population, and four to seven percent people in Delhi, Goa, Sikkim and Tamil Nadu were multidimensionally poor. That is to say, economic growth in Bihar has been less inclusive that in India as a whole.
The World Bank’s state brief on Bihar notes that “a large majority of Bihar’s workforce is still on the farm” and that it “has much ground to cover in health, nutrition and sanitation.”
Poverty and ill-health are inextricably linked. Poverty increases chances of falling ill as lack of finances leads to malnutrition (or poor nutrition in adults), impaired growth and inadequate access to healthcare facilities. If an individual is of poor health, he/she is pulling down the family’s productivity and accruing expense over healthcare. This is a vicious circle, a negative feedback loop which experts define as the health-poverty trap.
A recent example of this catch-22 situation can be seen in a diabetes survey conducted by Novo Nordisk Education Foundation as part of the pharmaceutical company’s India Diabetes Care Index report that records instances of the condition and its care in the country. As per the report, the Times of India has reported, “the number of patients with diabetes in India is now increasing in the low socio-economic strata,” proving that economic inequality breeds health instability.
Even as important organizations have pointed out gaps in Bihar’s development plans, we must admit the state has made significant gains in child health.
According to the National Family Health Survey-4, in the decade between 2005-06 and 2015-16, prevalence of wasting and low birth weight declined significantly. But, these progresses are not enough considering at least 48 percent of children aged under five in Bihar were stunted – the highest number in the country. The lives of kids are negatively affected in possibly permanent ways also by a lack of clean air, clean water and, most importantly, a healthy diet.
Encephalitis rears its ugly head every year around this time. In 2017, the BBC reported that “for more than two decades, apparently healthy children in a region of Bihar suffered sudden seizures and lost consciousness. Almost half died.”
If the epidemic has been a nearly annual occurrence, where are the precautions? Taking the past episodes as learning experiences, what safety measures did the government put in place to combat future incidents? Recent events answer these questions more cogently than I can hope to elaborate. Had the government put in place standard precautions and raised awareness among the citizens of the region, the danger could have been averted. But, learning from our mistakes has never been our strong suit.
Apart from the Lancet study mentioned above and several research papers on PubMed, scientific evidence detailing the clinical and epidemiological features of encephalitis were made available through a joint venture of the National Centre for Disease Control (NCDC) and the U.S. Centers for Disease Control and Prevention (US CDC) in 2013.
The Lancet research specifically points out that the absence of an evening meal significantly modifies the effects of the toxin in the fruit. Other studies also discuss the causes and effects of this type of illness at great length.
Despite all this encephalitis-related research, when precious lives are claimed by the ailment, it points toward a massive administrative failure and glaring lapses in the healthcare framework.
Taking into consideration the mass body of scientific work going into the investigation of encephalitis, the authorities could have displayed a level of preparedness, appointed a task force, and raised awareness about the illness.
Instead, every year these deaths are allowed to slide by, their relevance lasting only until they are news headlines.
Even hospitals and primary healthcare providers bore the brunt of the government’s lax attitude. Hygiene and healthcare provisions in some of the hospitals catering to these patients were not up to the bare minimum standards. In several cases, the incoming patients were just asked to seek medical care at another hospital, as the doctors were clueless about what to do to combat the situation.
Research based on clinical practices has revealed that administration of a certain level of dextrose within hours of onset is known to help the symptoms. Had the local healthcare providers been trained in recommended prevention strategies beforehand and the hospitals fully equipped, there would have been timely intervention and rapid recovery, and this situation would not have come to pass.
Even if we ignore the hard truths about government’s apathy and negligence, how can the state explain the fact that children were going to bed empty stomach. The only meal they ate comprised litchis. The families in the said region are most likely not in a position to afford dinner, which is why they resort to the easily available litchis to satiate their hunger.
Amongst the people residing around the litchi orchard area, there should have been rigorous awareness sessions. Considering the ailment affects children in a narrow age group whose bodies lack sufficient glucose due to under-nourishment, it was imperative that there were educative sessions on health and lifestyle choices, eating habits and hygiene. The government could have also arranged for meal programmes for the little ones so they didn’t have to go to bed hungry. These are real concerns of real people, yet none of this made its way to grand poll promises.
Mainstream politicians have failed the people who gave them the right to govern. That these failures border on incompetence is clear to those who are objective enough to see it.
No matter whether we attribute the tragedy to litchi consumption or not, either way the deaths in Bihar smack of government’s apathy.
This is not an elitist issue. This is not a political issue. This is not a propagandist issue. This is a quality-of-life issue. Thousands of precious human lives are at stake.
As law-makers and power-wielders, the statesmen are duty-bound to serve the people. We do not need complacent mainstream politicians who make false promises of a better future or dish out a load of baloney. We need politicians who are ready to take action, who are ready to go beyond poll propaganda to serve the nation wholeheartedly.
It is not rocket science to figure out what is called for: a sincere apology for mistakes made; a commitment to set things right; a credible plan for how to move forward.(Published on 01th July 2019, Volume XXXI, Issue 27)