What went wrong in Muzaffarpur? There could always be a debate on this. After all, the aetiology or the investigation into the causes behind the acute brain disease among children is quite complex and is constantly contested. But, most would agree something terribly went wrong on the part of authorities that it led to the death of as many as 140 children, if not more, in the district of Bihar.
T Jacob John, former president of the Indian Academy of Paediatrics and an expert who has undertaken field studies in Muzaffarpur, feels that there may have been a systemic failure in dealing with the outbreak, one that sadly has a seasonalcomponent to it. Anyone familiar with the geography would know that the problem surfaces typically during pre-monsoon months of intense heat between May and June. However, not more than 10-odd causalities had been reported in 2015 and 2016 during the same months. This is what has pushed many experts to suspect a systemic failure this time around. In fact, a few healthcare experts talk of a meeting held in Bihar sometime in second half of 2016 - post the outbreak season - that highlighted, if not celebrated, the success in overcoming this ailment.
So, what went wrong this time? On June 18, the Press Information Bureau put out a release saying that Harsh Vardhan, Union Minister of Health and Family Welfare, had chaired a meeting of a multi-disciplinary group of experts to deliberate on the factors causing high child mortality in the reported AES (Acute Encephalitis Syndrome) /JE (Japanese Encephalitis) cases in Muzaffarpur. They also discussed immediate measures to be taken up to prevent child mortality.
The release later quoted the minister as saying: "We discussed the socio-economic profile of the households which have reported the cases, their nutrition profiles, issues such as the ongoing heat wave, reported high percentage of hypoglycaemiain the children who have died, the prevailing health infrastructure in the district and other factors that could significantly be considered in these cases." According to the release, measures to further strengthen the health infrastructure, the need for an aggressive awareness campaign in the preceding months when these cases are reported in higher numbers in order to prevent these cases, the need for strengthening the research base to provide sound knowledge on the causes of mortality and active collaboration between the state and Central governments with experts and researchers, were some of the issues taken up for detailed deliberation at the meeting.
Malnutrition and health system failure
Rama Baru, professor at Centre of Social Medicine and Community Health at the Jawaharlal Nehru University, pointed out that the problem cannot be seen purely through the lens of either curative or preventive public health surveillance. Having studied community health issues closely over the years and having seen epidemics and their implications, Baru sees developments in Muzaffarpur as the ones pointing at a larger and inter-related issues of undernutrition and failure of healthcare system. What should not be missed out, according to her, is the class dimension to the problem of undernutrition among children under five.
Lychee, a safe fruit
In this whole effort at looking at the causes, solutions and lessons for future, Jacob John has an important reminder: "I see two outbreaks - one that killed the children and the other that is killing the lychee (litchi) industry." He underlines the point that lychee is an absolutely safe fruit for all adults and well nourished children. "In fact, people who can buy and afford the fruit, should buy and support the very families whose children are dying of malnutrition," he emphasised. Only those whoare under-nourished and have consumed lychee empty stomach run the risk of developing lychee-associated hypoglycaemic encephalopathy. This occurs when lychee is consumed after a prolonged fast by undernourished children. The presence of a hypoglycaemic agent methylene cyclopropyl glycine (MCPG) causes it. The disease pathway in such cases is linked to malnourished children slipping into hypoglycaemia in the morning when the glycogen reserves in their livers are limited. The situation makes them unable to mobilise glucose from liver glycogen. It doesn't happen with well-nourished children. The brain needs glucose, an important source of energy. Therefore, for these undernourished children, the body finds an alternate pathway to generate the glucose for the brain by the conversion of fatty acids to glucose called gluconeogenesis. However, if these children go to bed after consuming lychee, the methylene cyclopropyl glycine present in the fruit halts the process of conversion of fats to glucose. In the process, it releases amino acids, which harm the brain cells. This is called hypoglycaemic encephalopathy.
This does not apply to others. Ordinary children from reasonably well-to-do families and adults do not need an alternate pathway for making glucose. "While doing field work in Muzzafarpur in 2012, I found out that the disease was concentrated only in households surrounding lychee orchards in towns and villages there," says John.
So, what could have been done to prevent the situation from turning so grim? Recognising encephalopathy early is important, say experts, along with getting into intravenous administration of 10 per cent dextrose after the blood collection for glucose monitoring, a standard practice in such cases. In addition, awareness campaigns must be conducted to ensure that no child go to sleep without a cooked meal (to avoid long periods of fasting) and to increase parental supervision in order to minimise lychee consumption by small children (which in turn means minimising MCPG ingestion).
Arguably, what helped prevent such large number of casualties in the last couple of years, had been successful campaigns at conveying the message that no child should be allowed to go to bed without a meal. The questions, therefore, arise if authorities failed to conduct such awareness campaigns this time perhaps due to elections or some other known or unknown reasons. Also, were the children being directed to Sri Krishna Medical College without being intravenously administered for 10 per cent dextrose? This process needs to be done within four hours since the outbreak of symptoms, say doctors. What happened this year on this crucial standard operating procedure? Did failure to do this lead to the deaths of children who could have otherwise been treated? These are a few questions that require urgent answers.
This gets us back to the point that Rama Baru raised about malnutrition in Bihar. John agrees that malnutrition is a serious issue. He pointed out that the national family health survey in 2016 had showed that 45 per cent children in Biharunder five-year age were malnourished.