‘Most of these tragic deaths could have been prevented’

Chandrakant Lahariya

“THE true character of a society is reflected in how it treats its children” said Nelson Mandela. The tragic deaths of children in Muzaffarpur and other districts of eastern Bihar is another proof that India needs to do more for its children. This ‘do more’ can start with saving them from preventable ‘hypoglycemic encephalopathy’, improving their nutritional status, providing preventive and promotive health services and provisions for curative healthcare when they need it. The deaths in Muzaffarpur could be termed as a sum total of the political and societal failure on most of these fronts. Acute encephalitis syndrome (AES) is a name given to health conditions caused by a range of causative agents, including viral and bacterial infections (then termed, encephalitis) as well as non-infectious causes (encephalopathy). 

The AES cases have been reported from nearly 19 states and around 200 districts in India, with the majority coming from Uttar Pradesh and Bihar. The AES cases reported from eastern Uttar Pradesh, Gorakhpur included, are mostly caused by Japanese encephalitis (JE) virus. The non-infectious etiology (encephalopathy) is predominant in Muzaffarpur and eastern Bihar. It’s primarily attributed to a combination of the consumption of litchi by undernourished children, and then going to sleep without dinner. The litchi and AES link appears plausible (in the absence of a better explanation), though it’s not conclusive yet. By this hypothesis, all deaths in Muzaffarpur were preventable. Yet, the preventable mortalities seem not to have compelled Indian health policymakers to take sufficient corrective measures. 

The infant and under-five mortality rates in states such as Madhya Pradesh, UP and Bihar are nearly 4-6 times higher than Kerala and Goa. Which , in other words, means that 60-80 per cent of child deaths can be prevented by strengthening health services, AES deaths are in that category. The majority of the AES cases are preventable and treatable — preventable by vaccination or sanitation (as in Japanese encephalitis) and through appropriate education about nutrition to the vulnerable community. If the affected child is taken to a nearby primary healthcare facility within four hours of the onset of the disease, and administered 10 per cent dextrose, hypoglycemic encephalopathy (as in Muzaffarpur) can be treated. 

Prevention and control mission 

For a country aspiring to be a superpower and sending missions to Mars, if children have only litchis to eat and have to sleep without a meal in the night, it is tragic and shameful. If sleeping empty stomach exposes them to the risk of a deadly disease, it is also a matter of public health. It is a societal obligation and moral responsibility of the elected representatives and governments to intervene. To tackle the challenge in a sustainable manner, the immediate step has to be the launching of the AES prevention and control mission with sufficient funding. Considering such mission would need multi-sectoral coordination, it can be directly under the Prime Minister’s Office (PMO) and Chief Ministers’ Offices. 

More specifically, in context of the ongoing outbreak, the governments (union and state) need to ensure that the supplementary nutrition programme, including mid-day meal, are provided uninterruptedly, even during school holidays. There should be a provision for sufficient supply of ration through the public distribution system for the affected communities and public awareness campaigns on the importance of meals at night, especially for the undernourished children. 

There cannot be a better argument or opportunity to urgently tackle malnourishment and scale up POSHAN Abhiyan. The process needs to be fully supported by the existing functionaries and mechanisms such as Accredited Social Health Activist (ASHA), Village Health Sanitation Nutrition Committee (VHSNC), etc., under the National Health Mission as well as Anganwadis under Integrated Child Development Services. 

The strategies to prevent and control AES in India can be localised. JE vaccination and improved sanitation in districts affected with encephalitis and the harmonised interventions to address hunger and malnourishment in districts with encephalopathy are the two examples of this strategy. This should include training of staff in delivering preventive education and interventions, initiatives for improved nutrition and sanitation as well the strengthening of the primary healthcare services, where children receive timely and immediate attention for AES and all other health conditions. The AES deaths happen generally in states like UP and Bihar, where the primary healthcare system is weak. It’s another compelling reason to increase government investment on PHC as envisaged in the national health policy 2017. 

Need for research 

Alongside, there is a need to increase research on AES in India to understand the pathology and determinants and to design evidence-based programmatic interventions. The Standard Operating procedures (SOPs), for the prevention and treatment of AES, need to be updated and re-enforced at community and PHC levels. The elected representatives at all levels have to take responsibility, be accountable and lead these initiatives in affected areas. One of the consensus areas is that AES in eastern Bihar is affecting malnourished children, and this demands renewed focus on improving nutrition. In 2005, the Bihar Government had launched ‘Muskan: ek Abhiyan’ to increase immunisation coverage in the state. The initiatives catapulted Bihar from amongst the worst performers in immunisation coverage to a success story. Bihar can do the same for AES as well. 

In the weeks ahead, it is likely that the AES cases and deaths would decline; however, there is need for urgent and effective solutions, sustained over a period of time. If these deaths can make us commit to prevent AES outbreaks in the future, it would be a real tribute to the children who lost their lives. 

Rashtrakavi Ramdhari Singh Dinkar has written, Nahin paap ke bhagi keval vyaghra; jo tatasth hai, samay likhega unke bhi apradh. Interpreting this in context of deaths in Muzaffarpur, “It is not the virus or the toxin in litchi fruit, which can be blamed solely; history will judge us for ‘inaction and indifference’ in the ongoing AES tragedy”.  We, as a nation, have an opportunity to redeem ourselves. 

— The writer is a senior public health expert