The AES outbreak in North Bihar must be taken as another opportunity for India to reflect and brainstorm to decide a way ahead for future health systems
Since June 2, 2019, the extremely sad and disturbing news filtering out from Bihar’s Muzaffarpur and its adjoining districts, of young children dying from a mysterious syndrome, has revealed the helplessness of humankind, especially those who are less fortunate.
Acute Encephalitis or Encephalopathy Syndrome (AES), as it is currently known, is slowly turning out be one of the biggest challenges to otherwise accurate and well-developed epidemiological methods in medical science.
Since this outbreak was first reported in the mid-1990s (around 1995), thousands of children have died and many theories are proposed about the possible aetiology and mode of spread of this annual epidemic.
Bihar is also one of the regions where Japanese Encephalitis (JE) is endemic. Therefore, previously, this syndrome was being attributed to viral AES, due to infection of JE. Some studies attributed the cause to other groups of viruses.
In 2012, a paediatrician from Muzaffarpur who had the experience of treating many AES cases, published a paper and for the first time, proposed a non-infectious origin of this condition. He argued that these cases were not encephalitis but rather, encephalopathy, possibly due to hypoglycaemia and/or heatstroke.
Subsequently, another research paper was published in 2014 by T Jacob John, a renowned microbiologist formerly associated with the Christian Medical College, Vellore.
Based on his investigation, he suggested a toxic hypothesis of this disease. Methylenecyclopropyl-glyin (MCPG) is a type of toxic chemical typically found in the litchi fruit, which was suggested to be the probable cause of AES in the region around Muzaffarpur.
A similar fruit, ‘Ackee’, which also contains MCPG is abundantly found in Jamaica in the Caribbean. Ackee causes similar encephalopathy in children in Jamaica, known as ‘Jamaican Vomiting Sickness’.
In 2014, the Centre for Disease Control (CDC), Atlanta, USA, along with the National Centre for Disease Control (NCDC), New Delhi, conducted a detailed epidemiological investigation of AES in north Bihar, around Muzaffarpur.
The results of this study were finally published in the prestigious medical journal, the Lancet Infectious Disease in 2017. The findings from this research paper once again reiterated a non-infectious origin and suggested the toxin MCPG in litchis as the probable aetiology. This paper clearly suggested that consuming litchi with an empty stomach was a possible cause of toxicity, leading to encephalopathy.
Based on these major hypotheses, the probable reason for this mysterious syndrome can be clubbed into:
a) Hypoglycaemia due to hunger.
b) Heat stroke, especially among hypoglycaemic children.
c) Litchi consumption on an empty stomach causing MCPG toxicity.
Still, none of the hypotheses are strong enough to be conclusive and an easy counter-argument is possible for all of them. For example, hunger, heat and consumption of litchis are not localised in only the Muzaffarpur area. Nevertheless, one common factor among all cases was that the families belonged to poor socio-economic backgrounds.
For the future
So what are the serious lessons for public health systems and policy emerging out of this tragic outbreak?
First, it reiterates the fact that people’s health goes much beyond the realm of healthcare systems and is mainly a social issue. The social determinants of health, like, poverty, hunger and education are far more important than immediate factors.
Second, the inability to conclusively determine the causation of this condition highlights the limitation of scientific development and also reveals the obvious inequity in the distribution of scientific facilities.
The best of the tropical disease research centres are all located in the developed western world where incidences of such diseases are nearly negligible.
Third and most importantly, this incidence highlights the chronic challenge of health policy and health systems.
Such tragic incidences are an acute manifestation of the absence of ‘Resilience and Responsive’ health systems in any area. Associate Professor of Global Health at the Harvard TH Chan School of Public Health, Margaret E Kruk and her colleagues defined a resilient health system as ‘the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learned during the crisis, reorganise if conditions require it’.
Another similar incidence happened a couple of years back when the entire world was dazed by the devastating effect of Ebola and Zika. The high case fatality or mortality during these outbreaks can be attributed to the absence of resilience in health systems, more than the virulence of the causative organism.
Even within India, the containment of the Nipah virus in Kerala can be a textbook lesson for many other state health systems.
Another complicating factor is the presence of mixed health systems where both kinds of providers and financing, ie public and private are observed. In such a scenario, public and private systems run parallelly and often behave competitively.
More importantly, while the private sector caters to the majority of the health needs of the people during the regular period, the public sector is often left to languish in case of emergencies and outbreaks.
Many times, such mixed health systems display the symptoms of ‘mixed health systems syndrome’. A mix of public and private healthcare delivery of compromised quality and equity is diagnosed to have this syndrome. In such cases, care is predominantly provided by the private sector and public health systems are inflicted with management and performance issues reflected by poor responsiveness.
India is a classic example of the mixed health system and a state like Bihar witnesses an overt manifestation of the associated syndrome. Therefore, this outbreak and its disturbing consequences must be taken as another opportunity for India and a state like Bihar to reflect and brainstorm to decide a way ahead for future health systems.
As India aspires towards Universal Health Coverage, this outbreak and its distressing moments again emphasise the need to re-think about a more holistic healthcare reform pathway. While doing so, it would be a mistake to consider India as one single unit of health systems. The health system in India is not single but rather a compendium of 29 state health systems, each with its unique set of challenges and opportunities.
Vikash R Keshri is a public health and health policy researcher based at Patna, Bihar
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