How worried should we about AES Deaths in Bihar?

The government is mobilising to send staff and resources to address an outbreak of AES in Bihar. It will be a tough job when the public health system is in abysmal condition.

Bihar, once famous for its universities Vikramshila and Nalanda, and scholars like Kautilya, Aryabhata and Panini has now become the epicentre for a healthcare crisis.

Living through an Outbreak

As many as 157 children died due to Acute Encephalitis Syndrome this year. From toxins found in Lychees to heat and child malnutrition, there are several theories about the source of the syndrome. “Muzaffarpur district is famous for its lush orchards. So please do not blame only lychees for these deaths,” says paediatrician Dr Arun Shah, who has been researching about Lychees for the past three and a half years. 

He points out that the seasonal outbreaks have been reported since 1995 in Muzaffarpur, but there are chances that it must have been there earlier also. “Children from the lowest strata of society are affected by the disease. They go to orchards with their parents, who often work there, eat the fruits, come back and sleep with an empty stomach. They experience seizures the next day, morning,”  explains Shah, who has been working in the city since 1984.

Through the years, AES cases have been reported from several districts in Bihar: Gaya, Patna, Aurangabad, Saran, East Champaran, Sitamarhi and Vaishali.

The Syndrome

Shah points out that the children in his clinic in Muzaffarpur were found to have deficient blood sugar levels and signs of brain damage. While viral or bacterial infections cause encephalitis, many children were sick and dying due to brain damage.

Some of the critical challenges facing Bihar currently are low levels of education, poor healthcare services, underdeveloped infrastructure, low energy availability and social inequity. Efforts to stamp out the disease failed because many people don’t understand the condition.

An investigation published in The Lancet Global Health by the National Centre for Disease Control, India, and the U.S. Centers for Disease Control and Prevention, found “confirmation” that litchis contained a chemical called methylene cyclopropyl glycine (MCPG). These are naturally occurring toxins that cause hypoglycaemia and metabolic derangement in children.

When a child is malnourished, her body, turns to fatty acids in biochemical desperation to supply blood sugar to the brain. MCPG, the theory goes, thwarts this mechanism. It can send the brain into hypoglycaemic shock triggering convulsions and, if unaddressed, even death.

Some people in the region question why the government has not focused enough effort for awareness this year. Shah wonders why the government ignored the epidemic this year. “Children should not be allowed to skip their evening meal, they should avoid stepping out in the heat, and local public healthcare centres must stock up on rugs as well as dextrose. These were adhered to in 2017 and 2018. So that is why there were relatively fewer reports of AES.The recently concluded Lok Sabha election distracted the government from adequately preparing for the outbreak,” he adds

The key to stopping an outbreak is a robust primary care system. Muzaffarpur, where the AES has struck, has only 103 PHCs. Ideally, it should be 170. It also means that a vast number of people have not received care at the primary health centres and community health centres.

Ground Zero

It was a sweltering morning in one of the hottest Junes in Anshuman’s recent memory that he visited Muzaffarpur. The young public health professional notes that Bihar is a paradox. “Bihar is one of the poorest states in the country. Plus, we suffer from both droughts and floods.”

He also acknowledges that during his interaction with families with AES affected children in Muzaffarpur revealed that some of them did not even consume Litchis. “Insecticides or pesticides could also be another reason. The residue of toxins will be there on fruits. Children usually do not remove the skin of the fruits with their hands and usually remove with their mouths. The chances of toxins going directly into their body are higher,” he explains.

Another problem he says is the severe shortage of drinking water and the absence of functional sewerage system in the whole Muzaffarpur. “Sanitation is abysmal, even in the health facilities. Everyone thinks that Bihar is a backward state. I am from Muzaffarpur district, and Muzzafarpuriyas do complain about several civic issues like lack of supply of drinking water, erratic power supply, open defecation and pollution. That is the reason why residents staged a protest recently,” says the 28-year-old.

Is Bihar just an aberration? What is happening in Bihar is happening all over the country. The state is just a microcosm.   William Dalrymple, famously wrote that Bihar is a trendsetter for the rest of India. “The first ballot-rigging recorded in India took place in Bihar (1962)... first example of major criminals being awarded parliamentary seats took place in Bihar (1980)... So infectious is the Bihar disease that it throws into question the whole notion of an Indian economic miracle,” states Dalrymple in Caste Wars.

Why is it so hard to wipe out AES in the state?

Bihar is often considered as India’s cesspool. “The evidence of the first health planning document is from the period of Ashoka. So, Bihar is one of the first states to have a health planning document. But after economic liberalisation in 1991, Bihar was left behind due to socio-economic reasons. The government focused more on social empowerment rather than development. There was also acute political instability for several years, and this has  contributed to a weak public health system. There are several issues like high fertility rate and high population density, high rates of malnutrition and stunted children. The first thing that you notice when you come to Bihar is that even adults are weak, so their children are also weak, and the poor quality of food makes them weaker,” says Dr Vikash R Kesari, health policy and systems expert, The Centre for Health Policy, Asian Development Research Institute, Patna, Bihar.

He also notes that high temperature and humidity has a role to play in the spike of the number of deaths of children. “I am not ruling out malnutrition and lychees, but based on my discussions with physicians who have treated the children, heat could be an immediate trigger,” he adds.

“We have to look at the big picture. Doctors and paramedics are scarce in our Indian public health system, and these deaths are just a manifestation of the larger problem. We need to strengthen our primary care system and adopt a “bottom-up” approach rather than investing in tertiary care hospitals,” he concludes.

Probably then youngsters like Anshuman would come back to their home. “There are better facilities and better job opportunities in other cities. Little has changed in Muzaffarpur over the years, so why would a youngster come back?” he asks.