What’s causing encephalitis in Bihar’s kids and killing them – nothing else but malnourishment?
It is sad news, the number of children dead in Muzaffarpur, Bihar due to encephalitis has risen to 114 and unfortunately it does not look like it will stop at that. The children are from the lowest strata of society and not a single one is the offspring of a politician or a media anchor. But there is a lot of noise generated in discussions in the television studios and political circles. If at all there are any from the privileged background they have access and deep pockets to seek treatment in large corporate hospitals in the big cities or even fly out to the US for treatment. Only the politicians and the privileged class have this option. Meanwhile, the poor continue to die. As usual, there is a blame game to divert the attention from the real issues and the root cause analyses point to some bizarre conclusions. Chief among them is the pulpy seasonal fruit Lychee that is available in plenty in the markets in May and June of each year. There are scientific studies, but there is no conclusive correlation to lychees and encephalitis. In fact, the research papers have split the medical community with each side choosing to cite opposing research to substantiate their claims. One study conducted by the team of Dr. T. Jacob John, professor of virology and pediatrics at Christian Medical College, Vellore and Dr. Arun Shah, current president of Bihar state unit of Indian Academy of Pediatrics in 2016 are proponents of the Lychee factor as a contributing factor in the widespread brain disease in Muzaffarpur’s kids.
What is encephalitis?
Acute Encephalitis Syndrome (AES) commonly referred to as encephalitis is one of the many variants of a neurological disorder characterized by acute onset of fever and headaches that can escalate to seizures, disorientation, loss of consciousness, and even coma. Medical practitioners on the ground know very well that poor living conditions, low immunity, and undernourishment are the factors behind the onset of encephalitis.
We have a broken healthcare delivery system in India. The fatality rate in India is well above the global averages for AES. There is a wide range of causal agents such as bacteria, fungus, parasites, chemicals and toxins. The current outbreak in Muzaffarpur is diagnosed as hypoglycemic encephalitis, that is, blood sugar levels dropping to very low levels. Prolonged hypoglycemia often leads to irreversible brain damage and death. Treating doctors face the challenge of a very small window between diagnosis and treatment. The main causal agent in the recent outbreak is supposedly toxin-mediated and diagnosed as hypoglycemic encephalopathy. One popular premise is that Lychee seeds contain the toxin Hypoglycin A and Methylene-cyclopropylglycine (MCPG) that causes hypoglycemia. It is also possible that based on the presenting symptoms a blanket diagnosis is done and empirical treatment is started for toxin-mediated encephalopathy.
The severity of this outbreak and treatment is downplayed by shifting the focus to the consumption of lychee fruit. Do not forget Bihar produces more than 30,000 metric tonnes of Lychees each year that are sold all over the country and even exported. What is consumed by the poor children in Bihar is only a fraction and why are cases of AES not reported from the rest of the country where this fruit is consumed in large numbers. Walk into any supermarket in any city and you find lychees. One need not be a medical doctor or a researcher to understand that the identified toxins Hypoglycin A and Methylene-cyclopropylglycine (MCPG), if at all present, will be in very minute quantity in the lychee seed. Moreover, it is not the seed that is consumed and it is only the pulp of the fruit that is eaten. For the toxins to have any effect a large number of seeds need to be eaten and this is an unlikely scenario. Another possibility is the use of pesticides in farms. Traces of chemicals could remain on the fruits and get absorbed into the edible part of the fruit that may trigger the symptoms. Thus the outbreak of this endemic is a combination of administrative apathy, absence of infrastructure to tackle the outbreak, and a lack of political will to prevent it. One factor that cannot be ignored is that the focus should be on improving the socio-economic conditions with proper sanitation, hygiene, and encourage proper nourishment. With the outbreak of the endemic the deficient infrastructure and shortage of medical personnel just cannot handle the problem. The reality is that children are dying (full stop). It is easy to find a sweet cover up and blame it on Lychees. This will only be a dilution of the real issues. The lychee is an easy scapegoat for a larger problem of malnourishment in Bihar.
The larger issues
Muzaffarpur/Bihar and hypoglycemic encephalopathy outbreak is only a symptom of the rot in the public healthcare system in our country today. Doctors, politicians, and television hosts bandying about terms talk about one of the diseases that is repeatedly striking the poorest regions of the country. It exposes another aspect of untrained healthcare personnel in the country. It is possible that with all the media attention and the paranoia created about lychees, AES and the media constantly hammering this message, any child presenting with symptoms of fever and headache will be a pawn in the hands of unscrupulous private medical practitioners across the country who will jump to the diagnosis of AES and start unwanted treatment for AES. This will be a worrying trend because the doctors themselves will not be sure of what they are dealing with. The deficient public healthcare system is going to be stretched beyond the limits. We need governments with a vision and that is nothing but searching for a needle in a haystack. The blame for this endemic rests squarely on the Government.