Infanticide in Muzaffarpur

The annual Acute Encephalitis Syndrome (AES) infanticide to strike Bihar returned with perfect punctuality, exactly in the period between May and July. At least 150 children have died so far in Muzaffarpur, all belonging to poor families. Mercifully, rains have started and the AES cases are dwindling. The cause of death is attributed to hypoglycaemia, or low blood sugar, a condition linked to AES in Bihar. And why does hypoglycaemia happen? According to some members of the medical fraternity, it happens because of malnourishment and lack of proper diet; according to others, it happens because of the toxins released from fallen litchis, which hungry children eat off the ground, as well as malnutrition.

After a similar AES outbreak in Muzaffarpur in 2014, some research studies were conducted into the cause of the deaths. I refer to two Research Papers which suggest that AES plus hypoglycaemia happens in areas where litchi fruit is grown, and where children suffer from malnourishment. First is the 'Epidemiology of Acute Encephalitis Syndrome in India: Changing Paradigm and Implication for Control' 2014 which draws a parallel between cases in Bihar's Muzaffarpur and in Vietnam's Bac Giang province, where there are litchi orchards in the neighbourhood, and recommends that "The possible association with some toxin in litchi or in environment needs to be documented. Methylene cyclopropyl glycine (MCPG) which has been known to be a content of litchi fruit has been shown to cause hypoglycaemia in experimental animals." The Paper categorically states that "Under-nutrition has been identified as an important risk factor of developing AES. Children suffering from AES in Muzaffarpur, Bihar have been found to be associated with under-nutrition (short and underweight for age)." It further states that the disease mostly occurs among people of lower socio-economic background, living in rural areas, because the vector mosquitoes breed in rice fields and large water bodies, and that "poor access to safe drinking water, practice of open field defecation and poor environmental sanitation are some of the important contributory factors in the transmission of enteroviral encephalitis in children from lower socio-economic background."

The second study published in The Lancet is "Association of acute encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study." This study gives a break up of age and nutritional status of the 390 patients admitted between May 26, and July 17, 2014, to the two referral hospitals in Muzaffarpur. Most children were below six years, 16 per cent were wasted, and 65 per cent were stunted. The outbreak peaked in mid-June, with 147 cases reported during June 8-14, 2014, and declined substantially after June 21, 2014.

This study concludes with greater certainty than the previous one that "this is the first comprehensive confirmation that this recurring outbreak of acute encephalopathy is associated with both hypoglycin A and MCPG toxicity from litchi consumption. This illness is also associated with the absence of an evening meal. To prevent illness and save lives in Muzaffarpur, we recommended minimising litchi consumption among young children, ensuring children in the area receive an evening meal throughout the outbreak season and implementing rapid glucose correction for children with suspected illness."

I am not aware whether any follow up action was taken on the findings and conclusions of the above reports by the state administration, particularly for prevention. But I am aware that the state of public cleanliness, hygiene, and sanitation in Muzaffarpur District is extremely poor. Besides, the area is crisscrossed with streams, unclean water bodies and swamps, which in the intense heat and humidity very possibly breed the vector mosquitoes in the intense heat and humidity. This perhaps could be the reason that the incidence of the disease drops after the rains commence.

Television debates while discussing the Muzaffarpur tragedy have not gone deeper than the percentage of GDP spent on the Health Sector; the doctor-patient ratio, mismanagement and the poor state of government hospitals. The health experts very positively blamed malnutrition for the tragedy, and not having any special views on how to address this, the debate switched over to shortage of staff, beds and infrastructure.

Clearly, the aetiology appears extremely complex – a combination of poverty, lack of awareness and information, poor sanitation, and unclean water, water bodies breeding vectors, food insecurity and malnutrition. A combination of preventive, community and curative health measures, with a much greater emphasis on the preventive and community aspects, is required to ensure that these mass deaths do not happen in future. However, both preventive and community health require surveillance, and a sound and robust primary health care system. Unfortunately, this is the weakest and the least glamorous point of health administration and medical education. It is not another AIIMS or Speciality Hospital that is urgently required, but a functioning primary health care system focused on surveillance, community and preventive care, that can prevent such mass deaths in future.

Undoubtedly, the key driver for prevention is proactive action by the government to bring about the required behaviour change in families and communities – for ensuring public cleanliness, through public awareness and cooperation, accelerating the sanitation programme in the District, providing access to safe drinking water and information about proper storage of water, providing information to families regarding proper child nutrition within their earnings, and ensuring that ongoing health and nutrition schemes operate with full coverage.

Who will do this? Apart from the ASHA and Anganwadi workers, who unfortunately were not tasked with enough priority to take the required preventive steps, there are other field agencies in the village which the government wants to empower such as the women SHG Groups, the Panchayats. These can be trained, given responsibility, and guided to assist the government field functionaries to bring about the behaviour change first among themselves, and then in families and the community.

Coming to malnutrition, there is no doubt that it is the critical invisible and underlying factor within the multiple causes, that triggers infection by reducing immunity and preventing recovery. But clearly, in Muzaffarpur, in addition to malnutrition, there were other local factors that caused hypoglycaemia and the children's deaths, which are yet to be investigated. A look at NFHS 4 District data tells us that nutritional indicators of Muzaffarpur are not much different from North Karnataka Districts, with some indicators of Muzaffarpur being better. While the epidemiological investigations for the local causes of the AES epidemic go on, it is also essential that the elusive Poshan Abhiyaan initiates a special set of interventions to directly address the cross-sectoral nutritional causes of the Muzaffarpur tragedy, and also in other potential emergency districts with poor nutritional indicators.

I wonder if many people know that close by in Hajipur, there is a state-of-the-art industrial unit producing fortified energy food. But not an ounce of it is available in the local markets. It is all for export. It is hoped that the various teams of experts that have finally been sent from government of India come to a quick conclusion regarding the causes of this tragedy, and provide a clear and comprehensive road map to the state government on the steps to be taken for preventing such epidemics in future. Most importantly, a plan of action should be drawn up and implemented immediately.

(The views expressed are strictly personal)