Fix healthcare now, or future shock is certain

Whose children go to bed hungry? In a country with glaring social and economic disparities, hunger is a deeply political issue which many would like to dodge. But that is at the heart of the big story about the recent child deaths in Muzaffarpur, Bihar’s litchi growing belt.

At the time of writing, more than 100 children are dead of acute encephalitis syndrome (AES) and over 400 others with AES are being treated at various hospitals.

There are several theories about what caused such a large number of deaths this year. A combination of various factors — litchi toxins, extreme heat and humidity and malnutrition are seen to be responsible.

It comes as no surprise that in the early days, the blame for the AES outbreak was sought to be pinned on the litchi or rather a toxin in the fruit. This toxin reduces blood sugar. But we now know that overemphasising the role of the litchi toxin is to skirt the real issues that have led to such a horrific tragedy.

As various experts have pointed out, well-nourished children are not at risk if they eat litchis. The majority of the AES deaths in Muzaffarpur have been attributed to hypoglycaemia, or low blood sugar levels. This happens when undernourished children eat the fruit and go to bed on an empty stomach. A range of chemical reactions that kick in specifically in such cases due to the toxin in the litchi causes the hypoglycaemic encephalopathy. Encephalopathy is a disease in which the functioning of the brain is affected.

Northern Bihar and eastern Uttar Pradesh are no strangers to AES outbreaks. The point to note is that the recurrence is typically in areas that are impoverished and where large numbers of children are undernourished.

Nor is child malnutrition a new problem in Bihar. As Ronald Abraham and Andrew Fraker of IDinsight pointed out in a report published by the International Growth Centre a few years ago, over half the children under five years in Bihar were found to be underweight or stunted, indicating chronic malnourishment, according to the National Family Health Survey 3 (NFHS 3), which was carried out in 2005-06.

Recognising this, the Bihar government and the Central government had committed over '1,100 crores per year for the Supplementary Nutrition Programme (SNP), administered by the Directorate of Integrated Child Development Services (ICDS).

“However, programme funds are regularly pilfered, and on-the-ground public service delivery is lacking,” Abraham and Fraker noted.

In their report, they also pointed out that “in unannounced visits to 200 anganwadis across three districts of Bihar, 24 per cent of them were closed during times they should have been open, and meals were only served on 59 per cent of the days they should have been served. When anganwadis were open and meals were served, only 22 children on average out of 40 that should attend were present. And in these meals, only three quarters of the stipulated nutritional ingredients were used”.

The situation has improved, but only a little. The latest official data (NFHS 4) show that about 48 per cent of children (urban and rural) under five in Bihar remain stunted. The corresponding figure for rural children is 49.3 per cent. Children below five who are underweight in Bihar is 43.9 per cent, down from 55.9 per cent in 2005-06, but still unacceptably high.

The children who died needlessly in Muzaffarpur were the poorest of the poor in one of India’s most impoverished states. Most of the children are from the mahadalit community, including Musahar, and from other Scheduled Castes. Most of them were malnourished.

Their mothers are just as malnourished. Over 31 per cent of rural women in Bihar have below-normal body mass index.

The exact causes of the recent child deaths in Muzaffarpur is still not known but we know that despite the extreme heat, the undernourishment and the binging on litchis on an empty stomach, lives could have been saved with prompt and proper
treatment.

Which is where the second deeply troubling truth emerges. Many lives could have been saved with timely administration of an adequate dose of glucose. Experts say complete recovery can be achieved if children with hypoglycaemic encephalopathy are given 10 per cent dextrose (the name of a simple sugar that is made from maize and is chemically identical to glucose) within four hours of the onset of symptoms.

But for that, you need functional and well-equipped primary healthcare centres. In this case, much of the primary healthcare system in affected areas was near-dysfunctional.

T. Jacob John, a retired professor of virology from the Christian Medical College, Vellore, has done field research on AES. He points out that preventive steps are pretty simple — ensuring that that the children had a meal at night and timely administration of adequate glucose. But tragically, though systems had been put in place and the fatalities had dipped between 2016 and 2018, slippages happened.

John says primary health centres had got glycometers to check blood glucose levels of sick children in 2015 and doctors were directed to infuse 10 per cent glucose intravenously, irrespective of the results. But in a recent commentary piece in a national daily, he pointed out, “If only five per cent glucose is given, or if 10 per cent glucose is not administered within four hours, recovery is unlikely. I do not have detailed information from the field, but there seem to have been some human slip-ups this time.”

Clearly, there have been slip-ups in awareness drives by frontline health workers this year and there is some speculation whether this was due to the elections. Whatever be the case, health education was not sustained though experts like John and others made a series of recommendations.

If Muzaffarpur teaches us anything, it is simply this. Despite economic growth, India is still among the countries with the highest number of underweight children. And children are dying needlessly.

Child malnutrition is an uncomfortable truth that one ignores only at one’s own peril. It is deadly and debilitating, and a national peril as well. It not only affects chances of survival for children, it also raises their susceptibility to disease, lowers their ability to learn, and makes them less productive in later life. If it is not addressed at the ground level, and if the primary healthcare system remains in a pathetic state, not only is it going to be a tragic present, but extreme future shock is assured.