Muzaffarpur deaths: The continuing mystery of children who had no reason to die
It rained in Muzaffarpur on Friday. And till noon on Saturday, no fresh cases had been referred to SKMCH. Are we missing something?
That 150 children in Muzaffarpur have died is beyond dispute. All of them had two features in common. One- all of them, without exception, had extremely low levels of glucose in the blood (hypoglycaemia in medical terms) and second, they all belonged to the economically most disadvantaged section of the society.
Mainstream media as well as social media is rife with all kinds of speculation, hypotheses and theories about the cause and charges of negligence are flying thick and fast. In such a vitiated environment Truth often tends to get blurred. What adds to the confusion are 10 minutes or so of hard labour on the Internet by the uninitiated!
AES stands for Acute Encephalitis syndrome. Encephalitis means inflammation of the brain. Inflammation can occur due to infection or even without infection.
Doctors have now ruled out infection as the cause of inflammation in the child deaths in Muzaffarpur. Therefore, it is better to use the term Encephalopathy than Encephalitis. With this distinction we can safely rule out the links sought to be established between the deaths and involvement of pigs and the disease being a communicable disease.
However, the cause of Hypoglycaemia remains a matter of speculation. The speculative hypothesis put forward by a research team comprising of Dr T Jacob John (Prof of Virology CMC Vellore) and Dr Arun Shah (Prof of Paediatrics, SKMC, Muzaffarpur) in 2014 centres round a toxin called Methelene Cyclopropyl Glycene (MCPG).
This toxin is found mainly in Lychee seeds (which no one ever eats) and in smaller quantities in the pulp. A similar toxin MCPA (Methelene Cyclopropyl Alanine) is found in unripe Ackee fruit, which when eaten leads to development of Jamaican Vomiting disease. That Lychee and Ackee come from the same family and similarity in clinical profiles between the suspected AES cases in Muzaffarpur and cases of Jamaican vomiting disease provides strong credence to this hypothesis.
But why are only the poorest of the poor affected? Human blood glucose level is maintained in a certain range (80 to 140mg %). If the level goes high by ingestion of sugar containing food, insulin is secreted from the Pancreas. Insulin then helps control blood glucose levels by signalling tissues to take in glucose from the blood and used for energy.
If the body has sufficient energy, insulinsignals the liver to take up glucose and store it as glycogen. This happens in real time and the blood glucose level comes down. On the other hand, if the blood glucose level goes down due to fasting/starvation, Glucagon is secreted.
The action of the hormone glucagon is opposite of insulin. It causes mobilisation of glycogen to form glucose. If the bodies’ reserve of glycogen is exhausted or is low (as is the case in under nourished children), the body resorts to gluconeogenesis. Gluco neo genesis means formation of new glucose from other metabolites like protein.
It is postulated that the toxin MCPA blocks gluconeogenesis half-way if a starving undernourished child eats Lychee resulting in dangerously low levels of sugar (Glocose) in the blood.
Brain, unlike other organs, depends solely on glucose for its energy requirement (read-survival). Persistent low levels result in encephalopathy which is ominous for the patient.
However, there are certain discrepancies that does not allow the above hypothesis to go beyond the realm of speculation. As Dr SK Shahi, Medical Superintendent of SKMCH, Muzaffarpur has pointed out, a large number of children who died did not apparently have lychees while some had taken Lychee four to five days ago.
It is also worth noting that Lychee is grown in other districts in Bihar ( and with similar socio economical and nutritional features ). Why then is a certain geographical area so badly and exclusively affected, remains a puzzle.
Even in these areas with higher poverty and lower education, the children did not die in these numbers prior to 2009. Could there be something that researchers, doctors and public health experts have failed to stumble upon? The probability is high.
It rained in Muzaffarpur yesterday (Friday). And I checked as of Noon today (Saturday).No fresh cases were admitted in SKMCH. It is however good to remember that in medicine, absence of proof is not proof of absence.
The aetiology or the set of causes remain obscure but the treatment is actually very simple.
The problem is hypoglycaemia. The solution is glucose- early and rapidly. Early means before the hypoglycaemia has resulted in encephalopathy and rapidly means intra venous glucose, preferably 10% Glucose solution (commonly Glucose is dispensed as 5% but can be made 10% by adding additional quantity).
One might ask if it is so simple (it is actually simple), why did the children die?
The answer to this question leads us to the greatest paradox of ‘modern India’. Undernourished children in poor rural Bihar is a subject in itself that has been on the agenda of our policy planners since long.
With Lychee or without Lychee, the crux remains- (a) Avoid hypoglycaemia in the first place and (b) At the slightest suspicion inject Glucose. To give a meal to children before they go to bed and stopping them from playing under the scorching sun really helps.
Every single PHC or a health sub centre today, even in Bihar, has facilities to give Intra venous glucose. Even quacks run a thriving business out of IV infusion.
It has been alleged that because of the general election this year, the ground level health personnel could not educate the bottom of the pyramid about these simple things. As the problem reached a panic stage, the families preferred to bring their little ones to a better facility in the city, losing in the process, the golden hours that could have saved the unfortunate ones.
Rather than adding hundreds of beds to the hospital and/or making bigger ICUs, the emphasis should be on health education and strengthening our primary care infrastructure, both in terms of human and material resources.
Finally, the air of prevailing mistrust between medical professionals and the society that they serve also remains a factor somewhere in the background. Doctors on the ground would rather refer a patient to a higher centre than take the risk of trying to save a life and in the end get brutally assaulted for being unable to do so.
(The author retired from Army Medical Corps and is engaged in medical social service in north Bihar)