Over 150 children died in Bihar of acute encephalopathy in May and June, and about 130 of those deaths were in Muzaffarpur district alone. The other places that reported such deaths were Sitamarhi, Siwan, Motihari, Bettiah, Vaishali and Samastipur. There was a pattern in the deaths. The children were all malnourished and poor, an overwhelming majority from the Scheduled Castes, Backward Castes or Extremely Backward Castes—Mallah, Sahni, Majhi, Chamaar and Paswan communities—and some from Muslim families. All the children had fever and convulsions early in the morning, and most of them had gone to bed hungry the previous night. The outbreak coincided with the harvest season for litchi, the sweet fruit for which Muzaffarpur is well known. Some blocks in the district were more affected than the others—Kanti, Minapur and Musehari, according to Dr Sunil Kumar Shahi, Medical Superintendent and Director of the Shri Krishna Medical College and Hospital (SKMCH), the government hospital that handled most of the cases in the district.
Such deaths in the litchi season, however, have happened in other years in the recent past. In 2012, 235 children were admitted in hospital with the disease, and 89 of them died. In 2013, 90 children were hospitalised; 35 died. In 2014, 334 children were hospitalised; 117 died. Things improved after that: in 2015, there were 37 admissions and 15 deaths; in 2016, 31 cases and six mortalities. In 2017 and 2018, the mortalities were 18 and 12 respectively.
Dr Shahi said the pattern had held good since 1993-94: “This happens every year around this time. This year it has been particularly bad.” He added that the outbreak eased once the rains started. But this year the monsoon is delayed, and the crisis continues.
Some studies have linked the outbreaks to the consumption of litchis by undernourished children, though nothing is incontrovertibly proved. The Bihar government, loath to admit that malnutrition might be the most important factor fuelling the outbreak, seemed to clutch at the link when, in the second week of June, it issued an advisory not to feed children litchis on an empty stomach and to avoid consuming unripe litchis.
There was a backlash, however, as orchard owners, most of them from the land-owning Bhumihar caste, were upset that the outbreak was being linked to the fruit. Indeed, there were complaints that linking the fruit with the disease had brought down litchi sales. Finally, the government came round to acknowledging that poverty was the chief cause.
A quick government survey of the affected families produced an equally quick conclusion that they were all poor. That, however, did not require a government survey to establish. Almost all the affected children in Muzaffarpur were taken for treatment to the two district hospitals, SKMCH and Sadar Hospital, because their families could not afford treatment at the 50 or more private medical establishments in the town. A few children were taken to the privately owned Kejriwal Maternity Hospital. The SKMCH Director said that the hospital’s resources were stretched to their limits.
Dr Shahi said: “In 2014, the Union Minister for Health and Family Welfare, Harsh Vardhan, announced a 100-bed hospital. Nothing happened. That same year, samples were sent for testing to CDC Atlanta. But the cause of the disease was not ascertained. There is a standard line of treatment when seizures take place. We are implementing that. They [the affected children] are all nutrition-compromised.”
Indeed, for a disease that keeps causing deaths almost every year, the State government seemed curiously unprepared and unequipped to prevent and combat an outbreak. The government did issue instructions for wide distribution of packets of oral rehydrating solution (ORS) in villages, but that is hardly enough. As one ASHA (Accredited Social Health Activist) worker, who did not want to be named, said: “How will a packet of ORS help? No one seems to be taking responsibility for what is happening.” Other ASHA workers complained about the paucity of ambulances to take the sick children to hospital. Indeed, the affected families seem to have little access to even basic health-care services close to where they live (see box).
All the deaths in 2019 were divided by the (SKMCH) administration into two categories, “AES Known” and “AES Unknown”. (AES is the generic term for acute encephalitis syndrome indicating an infective agent as the immediate cause.) Of the 429 admissions at the SKMCH registered until June 22, 108 were “AES Known” cases. On June 27, the total number of fatal cases in the district, including the cases reported from Kejriwal Maternity Hospital, was close to 130, while the total toll in the State stood at 154. As things seemed to be getting out of control, a 15-member Central team was deputed by the Union Health Minister Harsh Vardhan to oversee, monitor and treat the patients arriving at the SKMCH. The team arrived in the second week of June.
The Central team, headed by Dr Arun Kumar Singh, senior paediatrician and national adviser of the Rashtriya Bal Swasthya Karyakram, a component of the National Health Mission, has been entrusted with looking at the aetiology of the disease, which now has been broadly classified under the umbrella title of acute encephalopathy, distinct from encephalitis, which may be viral, bacterial or fungal. (Aetiology is defined as the cause, set of causes or manner of causation of a disease or condition.)
Dr Arun Singh told Frontline that there was a need for clinical and epidemiological studies to identify the specific reasons for the affliction in Muzaffarpur.
There was also a belief that this year’s severe heat wave was partly responsible for the outbreak. Most of the affected children lived in cramped, poorly ventilated and thatched dwellings and did not have access to clean drinking water. They were also all malnourished with BMIs (body mass index) much below desired levels.
The other thing they had in common was the abundance of litchi trees in the areas where they lived. The trees are owned by landed people. Litchi pickers, who invariably belong to the lowest castes, begin their work at 4 a.m. in the morning and continue picking until 10 a.m. Their average daily wage is not more than Rs.60. Women are the main “pickers” and “sorters”, and they take their children along. The possibility of the children eating the fruits—the ones that have fallen to the ground and the ones that are discarded—cannot be ruled out.
The litchi connection
The litchi, undeniably, has emerged as a major talking point in discussions on the outbreak. The theory that the killer disease is caused by an infection is being re-examined in view of certain studies, notably one by the retired virologist T. Jacob John, who was commissioned by the State government to investigate child deaths during particular months of the year. In 2016, he and Dr Arun Shah, a paediatrician based in Muzaffarpur, jointly authored a study, which was published in the journal Current Science . Their theory is that Methylene cyclopropyl glycine, or MCPG, a toxin present in litchi, is a triggering factor for the mortalities.
Predominant symptoms of AES are hypoglycaemia, a dangerous decline in the body’s sugar levels, and dyselectrolytemia, or acute muscle weakness caused by the depletion of certain essential minerals. Chemicals found in the fruit, MCPG and hypoglycin, are known to have serious effects on the metabolic system, Dr Shah pointed out in a conversation with Frontline . He said that eating the fruit in the morning after having gone to bed on an empty stomach the previous night releases a toxin that reduces glucose levels drastically, leading to convulsions and even death if left untreated. Children from poor families in any case have depleted glycogen storage. The unripe litchi fruit also has toxins.
Dr Shah said this finding was confirmed by a team of experts from CDC Atlanta in 2017, though it did not acknowledge the earlier study done by him and Prof. Jacob John. Talking of why eating litchi has such deadly consequences in a certain section, he pointed out that no one from the cities had died of AES or the heat wave. He said that he had interacted extensively with the families stricken by the disease and had found that they had hardly anything to eat and lived in unsanitary conditions with their livestock.
He had observed from 1995 that children from similar backgrounds fell ill every year in Muzaffarpur in the months of the litchi harvest. Heat, humidity and poverty were not unique to the district and were part of life elsewhere in rural India, but children were not dying of the disease anywhere else. Why then was this happening in Muzaffarpur? “Why was it happening in the vicinity of the orchards? Litchi may not be the culprit, and the fruit has been consumed for the last hundred years. Are there genetic reasons? And why should one child in a family of four suffer? Girls were dying more than boys as girls were found to be more malnourished than male children,” Dr Shah said. “Heat and humidity are not the only reasons. Poverty, yes, but there are other parts of Bihar with acute poverty and high heat and humidity levels. We sent four samples of litchis to Lucknow for toxicology studies and it confirmed a high proportion of the two chemicals MCPG and Hypoglycin A. There were similar outbreaks in Vietnam and Bangladesh under similar epidemiological conditions including heat and humidity.”
Dr Shah had also observed that the cases dwindled away once the monsoon set in. It may not be a coincidence that the litchi crop is over once the monsoon arrives, and in any case the inundation of the orchards prevents children from foraging for the fruit.
A few years ago, the Bihar government issued a protocol regarding consumption of the fruit. There is a perception that this had something to do with the decline of fatalities after the last major outbreak of 2014. This year, there was no noticeable government activity on this front. That this happens to be an election year has been noted and there is a feeling that the government machinery was too busy with the election process to spare much effort on this.
Dr Shah said: “We prepared the SOP which had recommended an evening meal. If the midday meal could be extended to giving an evening meal to children of that age, it would make a huge difference. ORS is not going to help the child. It is given in diarrhoea and vomiting cases, not encephalopathy. Until May 23, no one was bothered about anything but the election. The litchi crop had started coming in. It was too late to intervene.
“There was a revised SOP in 2018 where we suggested that the movement of children should be restricted in litchi-growing areas. The government did not acknowledge our contribution to the SoP. Kerala is not a resource-rich State. Yet it has managed to reduce its infant mortality to levels that are comparable to those of Scandinavian countries.”
Misery near the orchards
Two-and-a-half-year-old Dinanath Kumar Mahto from Rautaniya village was admitted at the SKMCH on June 10 with fever and convulsions. He died on June 13. In local parlance, fever accompanying convulsions is referred to as “ chamki bukhaar ”.
Better-off neighbours from the same caste who work as auto-rickshaw drivers in Delhi pointed out that the Mahto hut was at one end of the village, an indicator of how poor the family was. “Look at their clothes. You will see how poor they are. There is no work here,” said Guddu Mahto, a neighbour who earns his living in Delhi.
The child’s parents, Chhattu Mahto and Nisha Devi, took the death stoically. Nisha is a litchi picker and sorter while Chhattu sells toddy. They could not recall whether the child had eaten litchis before he took ill. “He may have picked up something from the ground. He was mostly breast-fed. We give them something if there is food at home. We cannot sustain a family on Rs.60 a day. And then there is work only in the season,” said Nisha Devi.
Six AES cases were admitted from different villages in Karja Panchayat Samiti. Five were discharged after treatment; one did not make it.
Kanti Panchayat Samiti was among the badly affected areas. Of the 35 children admitted from there, 10 died. The oldest was 13-year-old Sunny Thakur from Narayan Beriyahi village and the youngest three-year-old Vikash Kumar.
Sunny’s mother, a widowed midday meal worker, is paid an honorarium of Rs.1,250 once in two months. Her children dropped out of school after her husband’s death. Although belonging to the Bhumihar caste, she is poor and is the sole breadwinner for her children. “I was away. My son was on his own. My brother-in-law took him to the hospital. I don’t know what he ate or whether he ate anything at all,” she said.
Anita Kumari, an auxiliary nurse midwife (ANM) in Kudhani block, Kharauna Panchayat Samiti, told Frontline that “such cases” always came up in the summer months. Paroo block in the Paroo Assembly constituency, which has only three doctors on regular duty, has also lost children to the disease. An ANM said: “Ram Babu Mahato’s eight-year-old daughter died in Mohabbatpur village after eating litchis. She developed convulsions.” In Karja block, another ANM, Neelam Devi, said she had distributed ORS packets and told parents to “feed their children well”. An upper-caste Hindu herself, she felt the poor were generally careless about their children: “These people leave their children lying around in the heat. They should also look after their children.”
‘Aetiology as important as treatment’
Dr Arun Singh of the Central team, who was not convinced by the argument linking litchi to the disease, felt that locating the causes of the disease was as important as treating it.
“At present, instead of focussing on the aetiology, we are trying to look at treatment and care. When we arrived, the ICU care was below standards in terms of equipment, management and understanding. Our first priority has been to strengthen the health management system. There has been research not backed by clinical understanding, and maybe it was not ethically correct to arrive at the conclusion about the toxicity in the litchi fruit,” he said.
He added: “Our collective hypothesis is that it is acute encephalopathy, and that hypoglycaemia is a manifestation and not the cause. One doesn’t know why the trauma has happened, but we have clinical leads which indicate a mitochondrial dysfunction. This affects the liver and other organs. We have to go to the community to see whether they are genetically lacking in mitochondria or whether diet or nutrition issues are affecting mitochondrial functions. In extreme heat, the demand of the body for energy increases. The child falls asleep owing to lack of energy. Our line of treatment looks at improving the metabolism of the affected children and giving them vitamins which are essential in the energy producing mechanisms. “Deranged” metabolism can lead to mitochondrial disorders. All this needs to be probed scientifically.”
In the majority of cases, the liver was found enlarged and with high ammonia levels. In the absence of a clear diagnosis, the children were being treated symptomatically for the fever and convulsions. As glucose levels were below the danger mark in almost all AES cases, glucose infusions were an integral part of the treatment. But then there were sporadic meningitis cases too.
A physician from the National Institute of Epidemiology, Chennai, who was part of the Central team, confirmed, however, that the pattern was more or less consistent in that the manifestation was confined to the months when the litchi was in season and that malnourished and poor children were affected.
In 2017, Peter S. Spencer and Valerie S. Palmer argued in a piece in The Lancet , titled “The Enigma of Litchi Toxicity: An emerging health concern in South Asia”, that this sweet tropical fruit ( Lychee sinesis ) and other members of the soapberry family contained amino acids that disrupted gluconeogenesis and fatty acid oxidation, a theory that Dr Arun Shah also supports. They also said that this had been established in the case of both the litchi and the ackee plant (origins in West Africa and transplanted later in the Caribbean). The ingestion of the ackee fruit, they wrote, had been known for decades in Jamaica to cause toxic hypoglycaemic encephalopathy in children. They said that recent litchi encephalopathy in India, Bangladesh and Vietnam could be caused by the rapid expansion of commercial litchi production across Asia. India is the second largest producer of litchi after China, and parts of Vietnam also grow the fruit. Bihar is the largest producer of the fruit in India, followed by West Bengal and Jharkhand.
Muzaffarpur, around 70 km from Patna, is famous for its litchi crop. Litchis grown in the district are exported and also sold in parts of northern India. Frontline interacted with families who work in the orchards. They said that the work fetched Rs.60 for six hours of work. While litchi production had stepped up in the last two decades, the cost of labour has gone down.
Even if there is a connection between the deaths and eating litchis on an empty stomach, advisories to send children to bed after a proper meal make no sense in a context when there is no way of providing food. Curiously, the families contacted by Frontline were not certain whether their children had eaten the fruit on an empty stomach. The deprivation is so stark and the absence of food so routine that memory does not retain the details.