Whose doors to knock in Muzaffarpur?

image source: Pixabay

Muzaffarpur is a district located 90 kilometers from Patna, the capital of the state. The headquarters of the Tirhut region of the Indian state of Bihar is also the fourth most populous city of the third most populous state in India. While kids were dying with the same velocity of ripe fruits falling from a tree, we as citizens and as the educated class decided to take back seats and be critiques. I suppose we strongly believed that criticisms would have saved those lives somehow. The two cities, Muzaffarpur and Patna are well connected and accessible via various transportation means. While the matter risks life of the child, it is a general assumption that the parents will go to any extent to save their kid, then why did these parents fetch their kids and put them on the bed with three other kids. As said, it is a general assumption. However, that is the exact case with assumptions? It has little to do with reality.

As a layperson and a common citizen of this country what affects us directly? Whether the ‘reason of the outbreak of the AES’, or now that it is ongoing ‘how to tackle it’? If to ask to a mother who lost her child and holds the dead in her arms, not wanting to let go, the only answer that comes is failed medical administration. Literally every person aware of the AES outbreak in Muzaffarpur has one entity to blame, it is the Government, IS IT? The media and people have one cry, “no facility for the poor”. Agitated myself initially without any actual reference to the books or ground study, I blamed the Government too. However, all it takes to get a reality check is to add a question tag to the statement. “The Government’s failure of administration and lack of medicinal facilities to the poor is the reason for the deaths of hundreds of children in Bihar today, IS IT?” No, honestly it is not. “What is the Government even doing?

 While we speak of Bihar, we cannot exclude the fact that here we are speaking of the third most populous state of India. Secondly, the parents involved are mostly wage workers. As it is out and loud, of parents who pluck litchis to make their living. However, I fail to understand what does money have to do while taking basic care of your child. Does it take money to pay attention to one’s kids?

A lot of emphasis was put on litchis being consumed empty stomached for nothing else to eat. The question is, where is the ration allowance of these families? Weren’t these families provided with any ration? The question to be raised as to what our Government is doing, the appropriate question is, With health insurance benefits, accessible public transport and more than enough ration to feed a child’s stomach, why did the kid have to remain hungry and consume litchi empty stomached? In addition, if the mathematics is going wrong, if the calculation does not fit, then maybe we are asking the wrong questions and pointing at wrong people.

 “Now it has won international encomiums for its delicious Shahi Leechi and China Leechi” my attention was but naturally drawn to the relevancy of the subject here. Litchi has become an extremely “bitter – sweet” topic for the entire state of Bihar right now. So, what is the connection in between the litchi of Muzaffarpur, now the Shahi Litchi and the deaths of these innocent lives? It was in October 2018 that the Muzaffarpur litchi got the Geographical Indication (GI) tag, thereby becoming an exclusive brand in national and International market. The famous Shahi litchi, which is famous for its sweet, juicy, unique flavour and aroma, is mostly grown in Muzaffarpur and neighbouring districts including East Champaran, Vaishali, Samastipur and Begusarai. The GI has been registered in the name of the Litchi Growers Association of Bihar, which had applied for the tag, said Bachcha Prasad Singh, President of Litchi Growers Association of Bihar. Before proceeding ahead, how many of us actually know what a Geographical Indication is? Forming a major branch of Intellectual Property, according to (World Intellectual Property Organization) WIPO:

“A geographical indication (GI) is a sign used on products that have a specific geographical origin and possess qualities or a reputation that are due to that origin. In order to function as a GI, a sign must identify a product as originating in a given place.”[1]

Owing to this, Muzaffarpur has the reputation as the home of Shahi Litchi.

How can something as sweet and as divine as a litchi cause deaths of hundreds of children? According to an article published in The Guardian, “Known locally as chamki bukhar, the disease claimed a record 150 lives in 2014. In 2015, US researchers had said the brain disease could be linked to a toxic substance found in the exotic fruit. They also said more study was needed to uncover the cause of the illness, which leads to seizures, altered mental state and death in more than a third of cases. Outbreaks of neurological illness have also been observed in lychee-growing regions of Bangladesh and Vietnam”.

Numerous news articles have been published by various newspapers and portals linking these deaths with the toxins found in litchis, others claim that it’s the concoction of poverty, malnourishment and the toxin found in Litchis, however the Director of the National Research Centre on Litchi. Dr. Vishal Nath rubbished these claims by saying that there is no connection between the outbreak of encephalitis and litchis; he further added that had litchi been the cause, it would have affected kids of rich families, as their consumption of the fruit is much more than the rural consumption. But that is not the case.[2]

With multiple articles surfacing online and in newspapers, with contradictory claims, partial and incomplete information, what source to rely on? What does the Government say about this? The National Health Portal regarding Acute encephalitis syndrome describes it as a serious public health problem in India as “acute-onset of fever and a change in mental status (mental confusion, disorientation, delirium, or coma) and/or new-onset of seizures in a person of any age at any time of the year. The disease most commonly affects children and young adults and can lead to considerable morbidity and mortality.

Viruses are the main causative agents in AES cases, although other sources such as bacteria, fungus, parasites, spirochetes, chemicals, toxins and noninfectious agents have also been reported over the past few decades.

Japanese encephalitis virus (JEV) is the major cause of AES in India (ranging from 5%-35%). Herpes simplex virus, Influenza A virus, West Nile virus, Chandipura virus, mumps, measles, dengue, Parvovirus B4, enteroviruses, Epstein-Barr virus and scrub typhus, S.pneumoniae are the other causes of AES in sporadic and outbreak form in India. Nipah virus, Zikavirus are also found as causative agents for AES. The etiology in a large number of AES cases still remains unidentified”[3].

The Government portal has a reference to multiple links out of which one refers to a paper published in the Indian Journal of Medical Research (IJMR), which explains in its causative infections of acute encephalitis, “Acute encephalitis is mostly caused by any of the many ‘neurotrophic’ viruses, many of which are vector-transmitted (arthropod-borne) arboviruses. In India, Japanese encephalitis (JE) virus is the predominant aetiology¹⁰. Due to its ecological features, namely, the requirement of ‘amplifying hosts’ (pigs, herons and egrets) and vectors (Culex species mosquitoes), there are geographic restriction to some parts of the country, mostly rice paddy growing areas, and seasonal restriction determined by vector density, mostly post-monsoon.[4]

The National Health Portal regarding the history of the disease says that it was clinically diagnosed in India for the first time in 1955 in the southern states of Madras, now Tamil Nadu. According to their data during 2018, 10485 AES cases and 632 deaths were reported from 17 states to the National Vector Borne Diseases Control Programme (NVBDCP)*in India, with a case fatality rate around 6 per cent. AES cases were reported mainly from Assam, Bihar, Jharkhand, Karnataka, Manipur, Meghalaya, Tripura, Tamil Nadu, Uttar Pradesh.[5]

Pertaining to this, the expert opinion of Dr. Shailesh Prabhakarrao Vaidya was sought, and I asked him as to what does litchi have to do with the deaths of these children? 1) Litchi isn’t only consumed by these kids but adults consume it equally 2) When people speak of toxins found in Litchi, they are directing towards something called Methyl Derivatives, which are found in the seeds of this fruit Litchi. And these kids aren’t consuming these seeds 3) Muzaffarpur Litchi Growers Association last year was given the Geographical Indication for SHAHI LITCHI; such Geographical Indication looks into the quality of the food. Had Litchis malevolent characteristics, it would not have gotten the certification. Hence, in my opinion Litchis have nothing to do with these deaths. 4) The only reason as to the connection in between Litchis and this disease is the season. Litchi is harvested around June and AES outbreaks around June too. That is how the dots are connected.

Which directs us to our following question, is it the first time that these deaths have occurred in Bihar, specifically Muzaffarpur? No, this has been so in the bygone times too. To make it more political the media suggested that since 2014 – 15 the death numbers had come down owing to the awareness campaigns by the Government. However, this time because of the elections the campaigns took a backseat and hence the death toll rose high. As to the cause of the deaths, for the Bihar health authorities, the disease has remained a mystery. They do not decisively know if it was the mosquito-borne Japanese encephalitis that spreads from animals to humans or it is Acute Encephalitis, the one that spreads through contaminated water. Or it is simple Hypoglycemia (when the level of glucose in the blood falls below normal) caused by Litchi consumption.

With such technical chaos going on, all that the media did was point towards the failure of the government. May it be regarding the awareness campaign, medical facilities or the negligence towards the poor, at the end the knock had to be at the authorities’ doors. These irresponsible and flawed acts of media led to the fueled agitation of public, which is never served with the facts but is always manipulated for either gaining votes or views. Some litchi growers have blamed the excess of pesticides used on these litchis and not the toxin in the litchi fruit (safeguarding their bread and butter; litchi). These litchi – growers admitted that strong pesticides containing cypermethrin were spread on the litchi trees to protect the exotic fruits from insects and bats. Further, they added that the excessive use of these pesticides and plucking of litchis before expiry of the pesticides are behind these deaths. In addition, some growers sprinkled the drugs mixed with water, which are used to treat domestic animals, which are on these litchis, and these children consumed the same.  The National research center on Litchi in Muzaffarpur had advised restricted use of the drug as it is harmful to human body. However, most litchi growers avoid the guidelines and excessively use the same in order to protect their litchis. The Director of the National Research Centre on Litchi in Muzaffarpur, Dr. Vishal Nath said that the center issues guidelines from time to time regarding the same but if the litchi growers are not to adhere by the same then he does not know how to help. While everybody is trying to cover their heads and secure their own interests, it is the common person, minus any technical – medicinal knowledge who is hung out to dry in the sun.

Living in a political entity as India, which is a democratic republic, we as citizens have often been highly unaware of our rights and rather tend to misuse them. Of course, blame it on the Government again! It has absolutely nothing to do with our incompetence and zero will to acquaint ourselves with our own rights.

Initially, it has always been about unawareness, we did not know our rights and hence there was no question of exercising those. However, today that we are well acquainted with our rights, what do we do with those? We as responsible citizens choose to overuse our rights, we consciously make decisions wherein we exercise our rights full – fledged and totally ignore our duties the way we ignore red signals while driving; it is a matter of convenience for us Indians.

"It never happens in the rich and developed Nations, look at their governments successfully implementing the schemes for their middle class and Poor! No deaths as such, it happens only in India.", let us check the veracity of this claims.  

According to an article published in the Chicago Tribune, in the U.S. on March 19, 2019:

The New Jersey-based SUDC (Sudden unexplained death in childhood) Foundation and the Centers for Disease Control and Prevention estimated that about 400 children in the U.S. die these mysterious deaths each year — the fifth leading category of death among 1- to 4-year-olds — though researchers say the number is likely higher. According to the CDC (Centers for Disease Control), about 3,500 babies die each year from Sudden Unexpected Infant Death, or SUID, the term used to describe the death of children younger than 1-year-old. SUID includes SIDS (sudden infant death), which is much more well-known than SUDC.[6]

As per a similar article published in The Telegraph, in U.K. on May 22, 2019:

“Every year, up to 27,000 children aged five and under are diagnosed with sepsis, a life-threatening complication of infection. Estimates suggest that up to 4,000 die every year from the condition."

If to focus on statistics in order to determine India’s ranking in infant mortality rates then, according to CENTRAL INTELLIGENCE AGENCY (US) as of January 01, 2018. Afganistan tops the infant mortality rate on rank 1. by 110.6 deaths behind 1000 births in the same year. With Pakistan ranking 25^th by 52.1 deaths, India on the 47^th rank by 39.1 while other countries like the U.S, U.K and Russia holding 170^th, 185^th and 163^rd ranks respectively[7]. Based on this, if we compare India’s ranking with other Super Powers because we as a country claim to be one soon, then we would find that there is a good difference of 123 countries in between. While we as a country have secured our name in the first 50s of this death list, the super powers range in between the last 50.

Yet, children are dying in hundreds in the west too. Disease does not see the power of a Nation before victimizing its citizens. Neither does it see the political identity of a person. Of course, these facts are co related to the way the disease is tackled and recovery of the victims.

Getting back to, what has the Government done in order to secure the health of its citizens? The Government has come up with multiple schemes ensuring the health of its citizens. In addition, these schemes are not generic or standard which will only fit a certain portion of society. National Health Insurance schemes reach these families depending on their social and economic eligibility.

These six schemes are:

1.Rashtiya Swasthiya Bima Yojana (RSBY)

2.Employment State Insurance Scheme (ESIS) 

3.Central Government Health Scheme (CGHS)

4. Aam Aadmi Bima Yojana (AABY)

5. Janashree Bima Yojana

6.Universal Health Insurance Scheme (UHIS)[8]

To speak of Muzaffarpur specifically and the health administration, according to the official website for Muzaffarpur, the district has in altogether 1811 villages, with 16 administrative blocks, 29 Police stations and 16 revenue circles. There are in toto 16 Primary Health centers, 1 health centre for each block; it has 83 Additional Primary Health centers, and a good number of 500 Health sub centers. The proposed budget for these 16 blocks for the year 2018 – 19 is of rupees 4091.87 lakhs.

Now when the health administration isn’t half-bad of what the media claims, then why weren’t the kids carried to these centers? The schemes mentioned above do cover the less privileged sections from Muzaffarpur too; the rules pertaining to these schemes are not hard and fast, rather lenient because the framers have tried making it as user friendly as possible. Irrespective of the fact that the schemes are Government run, the families are given the options of Private or Public hospitals. The Private hospitals have no plausible reason to send the patients back or deny admitting them because the Government under these schemes reimburses the entire expenditure of the medical bill of people availing these schemes. Rather there are hospitals trying to make fake records to fish money from the Government under these schemes, so the question as to the hospitals denied patients or poverty does not come into the scenario.

Dr. Vaidya further cleared the air with his study on the subject, according to him, Hypoglycemia is the reason behind the death but it is the AES, which leads to Hypoglycemia. This added more to my confusion and hence he explained it further. Dr. Vaidya said that, “AES basically is a cap and a roof for viruses with similar symptoms and which haven’t been successfully researched on, hence all such viruses with similar symptoms are capped under the word Syndrome, here in this specific case called as AES, Acute encephalitis syndrome”.  

How is Encephalitis and Hypoglycemia leading to deaths? As said already, AES is a cap for viruses, now to speak of viruses, this particular virus that is killing children in Muzaffarpur activates throughout the night, specifically after 12:00 am. Hence, in the mornings, the symptoms could be seen and that is the same reason why these kids fall ill in the mornings. Therefore, what exactly happens is that the virus feeds on the sugar inside the body, at night when these children fast and go to sleep empty stomached, their sugar level which generally goes low throughout the night descends even further, leading to a stage called, “Physiological Hypoglycemia”.

As to the symptoms of the disease: The immediate parent, guardian must look out for 1) difference in the behavior of the child 2) whether the child is sleeping more than usual or losing consciousness  3) if there are any seizures. If these symptoms can be seen then the child should be rushed to the hospital immediately. 4) The fever need not be high, low fever is a symptom too.

Treatment for this: The first and foremost treatment for this is a proper dose of IV DEXTROSE, i.e. intravenous bolus of dextrose because of this the sugar level will rise up and the disease will not reach it’s further stages like, death of brain cells, etc.

Whether recoverable and the Golden hours:  yes, recovery is sure if the treatment starts before 04 hours from the appearance of the symptoms. Once the IV DEXTROSE is given the patient’s body will start its own recovery, antibiotics will not help as to AES does not respond to Antibiotics.

Along with his expert opinion on the technicality of the subject, Dr. Vaidya also enlightened us regarding other schemes run by the Government such as Integrated Child Development Services (ICDS), Pradhan Mantri Swastya Suraksha Yojna (PMSSY), Maternal Health Programme (MHP) etc.

Conclusion: 

 From the research conducted and expert opinion sought, it will be a safe conclusion to say that the outbreak of AES is controllable. As the virus of AES reduces the glucose in the body and leads to hypoglycemia. The treatment for hypoglycemia is IV DEXTROSE, however, logically and medically, what is the preliminary in house treatment for this Hypoglycemia? Considering the Golden hours are about to expire, an instant treatment will be needed to keep the health of the child from deteriorating further. What would be an instant sugar booster? Table sugar, sweet toffees/ chocolates, glucose etc. are the first options that we consider. However, it is suggested that table sugar is not ideal because of the fructose/glucose combination, which slightly slows the absorption. Avoidance of any candy with a sugary shell such as Skittles, M&M’s, Rockets, and many others, particularly chocolates is also suggested as these will be digested much slower due to the waxes and fats contained. As an alternative to dextrose glucose tablets work fine. Another approved alternative is glucose/dextrose powder (not to be poured in mouth directly), which is normally more accessible than tablets.[9]  

If to speak of amenities, Muzaffarpur at least according to the books has enough health and transport facilities, it has sufficient number of Primary health centers, sub centers, public and private clinics, transportation. To balance this, any doctor with basic education would know what hypoglycemia is, then why aren’t such doctors spreading a word as to the in house treatment that could be given to the children there? Why are these public hospitals not running awareness campaigns? Isn’t it the concerned department's work to first study the circumstances and needs of a place before appointing and posting a doctor there? Why are we lacking in organization?  Do these primary health centers have functional doctors or are these doctors running their private clinics? One can raise so many questions to the Government and administration. But, what about the dirty laundry we have in our house? The NGOs, these NGOs can gather people in order to agitate against the authorities, why couldn’t these NGOs collect basic amount of 50,000 and distribute the glucose packets while running an awareness drive. At the end, all that one kid needed was few grams of sugar!

-      Medha Patel.

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[1]https://www.wipo.int/geo_indications/en/

[2]https://www.indiatoday.in/india/story/litchi-encephalitis-director-research-centre-1555505-2019-06-25

[3]https://www.nhp.gov.in/disease/communicable-disease/acute-encephalitis-syndrome

[4]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5761025/

[5]https://www.nhp.gov.in/disease/communicable-disease/acute-encephalitis-syndrome

[6]https://www.chicagotribune.com/lifestyles/ct-life-sudden-unidentified-death-children-20190228-story.html

[7]https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

[8]https://www.nhp.gov.in/national-health-insurance-schemes_pg

[9] https://www.diabetesdaily.com/blog/ideal-treatments-for-hypoglycemia-and-some-alternatives-520580/