The continuing scourge of Bihar

The continuing scourge of Bihar



With the Supreme Court ordering an enquiry into the deaths of children in Muzaffarpur, and the district Chief Judicial Magistrate ordering a probe against the Union Health Minister Harsh Vardhan and Bihar Health Minister Mangal Pandey in a case of negligence registered against them, the judiciary has at last taken note of the outbreak of Encephalitis that has claimed the lives of 150 kids so far. The Acute Encephalitis Syndrome (AES) has also led to hundreds of children being admitted to hospitals.

The probe ordered by the CJM has been in response to a petition filed by a social activist Tamanna Hashmi which said that both Vardhan and Pandey had failed to fulfil their duty to control the outbreak of Encephalitis and that both had done nothing to create awareness about the disease in the affected areas despite the fact that AES had been killing kids for years in that district.

In fact the disease is not new to the region. In 2012, it had wreaked havoc, claiming 424 lives and the next year the Encephalitis related toll stood at 222. In 2014, 379 deaths were reported and in 2015, 2016, 2017 and 2018, the toll was 90, 103, 54 and 33, respectively. The Centre has also been criticised for failing to act on its promises. During his visit to Muzaffarpur at the time of the 2014 outbreak the Union Health minister had promised a super-specialty hospital, including for kids, and during his visit this year he repeated his promise and said that the hospital will become operational within six months. Meanwhile, several Bihar leaders, including the former Health minister CP Thakur have urged the Prime Minister to visit Muzaffarpur to take stock of the situation.

Muzaffarpur has also hit the world headlines as the worst place for a child to be born, replacing some of the poorest countries of Africa.  While the state and the Centre have suddenly woken up and have been grappling with the situation, records suggest that the Bihar Government has been consistent in its neglect of child nutrition and general health care, thus making this a fertile ground for the outbreak of the disease. Encephalitis has not been a stranger to the region of North Bihar and Eastern Uttar Pradesh either. The Japanese Encephalitis (JE) that claimed 500 lives in Gorakhpur as the new Chief Minister of UP took over two years ago had been attributed to the abysmal condition of the hospitals there with oxygen cylinders being non-operational.

According to the National Family Health Survey (NFHS) Muzaffarpur has an abysmal record as far as child nutrition is concerned, with nearly 48 per cent of children under the age of five being stunted, too underweight with glaring signs of chronic malnutrition. Compared to this only 31.3 per cent children in Africa are stunted and on an average 6.3 per cent children there are wasted as against 17.5 per cent in Muzaffarpur. South Sudan is the only country that fares poorer than this district in Bihar.

The deplorable state of health infrastructure and services led the National Human Rights Commission to issue notices to the Centre and all the states underlining loss of lives of children in Muzaffarpur. The NHRC identified Bihar, Uttar Pradesh, Haryana and Punjab as ‘vulnerable’ in health facilities. All these states have implemented Ayushman Bharat scheme. In fact, despite concerns being expressed, health authorities and local communities paid little heed to warnings five years ago that lichis can trigger the illness in undernourished children if they skip the evening meal.

A pediatrician in Vellore and a toxicologist in Lucknow, who both played disease detectives and first proposed the intriguing tripartite connection between poverty, lichi and a life-threatening illness in 2014. It is believed that greater medical preparedness and public awareness could have helped check the toll.

Their studies between 2012 and 2014 had suggested that lichi pulp contains a blood sugar-lowering chemical called methylene cyclopropol glycine (MCPG) that triggers hypoglycaemic encephalopathy (brain damage caused by low blood sugar levels) when taken after a prolonged fast by undernourished children.

A joint study by Indian and US researchers in 2017 had also confirmed that the blood sugar-lowering chemicals in lichi can lead to encephalopathy. The scientists had then recommended that all kids receive an evening meal before sleeping and that young undernourished children not consume too many lichis.

Most victims have been from the poor socio-economic background for whose benefit the government had launched its ambitious medical insurance scheme Ayushman Bharat last year. Under the scheme, beneficiaries are entitled to cashless medical care in government or private hospital up to Rs 5 lakh and in his address to Parliament, the President Ram Nath Kovind had said 26 lakh people have availed of treatment under the scheme.

But reports from Bihar suggest that not more than 35 children suffering from brain fever availed treatment under the scheme despite the National Health Authority (NHA), which oversees implementation of Ayushman Bharat, writing to Bihar government to ensure that those suffering from brain fever should be provided insurance coverage.

The reason for this low coverage remains unexplained and the answer could lie in the eligibility criteria and pre-treatment verification process, most victims being from the poor socio-economic strata.

In Bihar, more than 16 lakh people have enrolled under the scheme and around 45,000 have availed of treatment.

The problem, particularly in Muzaffarpur, is that a large number of those affected do not know how to go about availing of the scheme, and there has been confusion among the target population about how to get even the Ayushman Bharat e-card. Even the fact that anyone with a BPL card is eligible for treatment under the Ayushman Bharat is not known to them.

According to T Jacob John, formerly of the Vellore Christian Medical College ‘The joint India-US study corroborated what we’d proposed in 2014, still even today there appears to be some reluctance in acting on our recommendations.'

The Lancet Global Health published in January, 2017, results of a collaboration between experts of the National Centre for Disease Control (NCDC) and the US Centers for Disease Control and Prevention (CDCP) that claims the scientists zeroed in the cause behind the outbreak in Muzaffarpur, involving seizures, slipping into a coma and claiming the lives of many, mostly children. Muzaffarpur is India’s largest lichi cultivation region and many children of labourers consume the fruit as it falls to the ground, while skipping their evening meals. Previous studies had reached different outcomes, including heat stroke and bat viruses.

Scientists from the National Research Centre on Litchi (NRCL), in Muzaffarpur, however have rejected the Lancet report and Sushil Kumar Purbey, a senior scientist at NRCL, has said tests carried out by the researchers seemed ‘inconclusive and contradictory in nature,’ adding that they were ‘preparing a reply that we will send to the researchers associated with these findings soon.’

Brij Mohan, a professor of paediatrics at the S.K. Medical College in Muzaffarpur, observed that most children who died had low blood-glucose levels but they were all malnourished and that the number of children brought to the hospital had reduced significantly to 60 admissions in 2016. ‘Children are still eating lichis but not falling ill.’

Whatever be the reason, the Lancet study has cast shadows over lichi consumption. Perhaps there is more to this, as Mohan says, but further research is definitely necessary to settle the dispute.

Many experts, including John, wonder whether some of the deaths in 2019 which, like earlier ones, have coincided with the harvesting season and could have been averted through appropriate responses by the public and the health community. ‘Unfortunately, health authorities sometimes disregard evidence, even strong evidence,’ said John, who had been invited by the Bihar government in 2012 to probe the AES at that time.

John had examined the  children’s medical charts and noticed some peculiarities: they had all developed symptoms within hours, typically in the early mornings; their illness had a fast course, causing death within three or four days; and their spinal fluid did not show signs of infection. He recalled reading about an illness, the Jamaican vomiting sickness that occurred in children who consumed the ackee fruit.

‘Unfortunately, health authorities sometimes disregard evidence,’ said the doctor. He teamed up with Mukul Das, a senior scientist at the Indian Institute of Toxicology Research, Lucknow, who showed through laboratory studies the presence of the sugar-lowering chemical in lichi pulp. Das’s studies also showed that MCPG causes hypoglycemic encephalopathy in laboratory animals.

‘We’re not suggesting that every child admitted has hypoglycaemic encephalopathy,’ conceded Das. ‘But the coincidence with the lichi harvesting season makes this likely. It is sad that health authorities are still searching for viruses, or citing heat stroke or pesticides after so many years.’

Some relief came the way of the Yogi Adityanath government, when encephalitis deaths dropped in the 14 most-affected East UP districts by over 66% last year from 2017 when such deaths had dominated the headlines. Between 2016 and 2018, at least 228 cases of Japanese encephalitis (JE) were reported in Bihar alone, claiming 46 lives.

On the subject epidemics, one that was the scourge of parts of India and was totally eradicated by the eighties of the last century in a remarkable collaboration of civil society and care givers and by some divine intervention needs to be mentioned. Recalls a doctor who was part of it, ‘The first time I saw a village full of people dying of small pox, it was like an image from Hieronymus Bosch engraving of Dante’s Inferno.  When I arrived in a jeep with a big UN seal on it, he recalled, a mother rushed up carrying a four-year-old boy. She asked me to heal him, but the boy was long dead. Everywhere there were children coughing, covered with excruciating lesions. Parents were standing watching helplessly. Some places, we were told the rivers did not run because they were clogged with bodies. Arguably the worst disease in human history, it had already killed half a billion people including two dozen kings and emperors and dictators. Wealth and privileges could not protect you from the excruciating death with pustules and scabs covering every inch of the body.’

Larry Brilliant, the doctor recalled, ‘When we began there were no intensive care rooms, no clinical care, no treatment options, only the fight to prevent the next case. There were 200,000 cases in India in the year we began, and one third of the victims died. To eradicate it we had to find every case in the world, every virus, without exception, and put a ring of immunity around it. So, over the next few years 150,000 health workers visited every house in India searching for hidden cases. We made one billion house calls and in October of 1977, I got to the most remotest bottom of Bangladesh to see what would be the last human infection in nature of Variola Major, the end of a chain of transmission of the disease that lasted more than 5,000 years and that had killed Pharoah Ramses and had scarred the faces of many of Jesus, Moses and Buddha’s disciples. A young girl, Rahima Banu in Bhila Island in Bangladesh, when I saw her after her scabs had fallen and thought when  she coughed and the last of virus fell on the hot patched land  of Kuralia village the last virus had died  from that chain of transmission  going back to the time of the Romans. I cried like a child.’

He said he spent 10 years in India and Asia fighting smallpox and had been the youngest member of the WHO’s small pox team and the last to leave.

After they eradicated smallpox, some of the warriors started the Seva Foundation to apply the same kind of scale to giving back sight surgically to poor blind people.’ We took what we learned in smallpox eradication and raised funds from old friends like Steve Jobs. By driving the price of a sight restoring operation to (then) 5 dollars, we could deliver service at scale to anyone in the world. We and our partner, the Aravind Eye Hospital, have restored sight to more than 3 million people.’

Despite the epidemiological turf war between pathologists and the elaborate and ambitious healthcare schemes with much digital paperless data collection, if they have not been able to tackle the Encephalitis problem in one district, they could as well have taken a leaf out of the previous eradication efforts that had been successful with some inspirational collaborative effort. Such miracles can still happen.