Litchi : The Cynosure of Health Professionals

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Muzaffarpur in Bihar is the largest litchi farming area in India. Litchi is the main source of revenue for the city, and now it’s the leading cause of children’s deaths. What is the mystery behind the litchi deaths? Why the state government did not yet take out any plan to contain this recurring phenomenon? How doctors and diagnostic labs are reaping benefits from the disease? Our Senior Features Editor Dr Nishindra Kinjalk delves deep into the issue to explore the truth behind the killer Litchi.

People of North Bihar have been suffering for years due to the regular devastation caused by the yearly floods brought by the rivers streaming down the hills of Nepal. To add their despair, there has been scourge of mysterious deaths of infants and young children during hot and humid summers. The suffering of children have mostly been reported from Muzaffarpur, the largest city of North Bihar, better known for its famous delicious variety of fruit the ‘Shahi’ litchi. A new dimension added to their woes when suddenly on the February 1, 2017 Indian as well as the western media got flooded with the news blaming litchi as the cause of the death of these children. The cause of concern was much deeper as it was first published in Lancet Global Health, a reputed medical journal.

The economy of North Bihar has been dependent mainly on its rich agriculture produce. The cash crop has mainly been litchi, sugarcane, mango and tobacco. The litchi, especially the ‘Shahi’ variety has been very popular not only in India but globally for its musky odour and exotic taste. The term ‘Shahi’ itself refers to its meaning ‘belonging to the royals’. Litchi here has three more famous varieties named Chinia (sweet), Laungia (small in size) and a seedless variety. The season usually begins in mid May and comes to an end by the first week of June. The big orchards are sold to the traders from Varanasi, Allahabad, Kolkata, Delhi and Mumbai; often sold much in advance, at times even for more than five years.

The web of the rivers and the alluvial soil makes this area very humid. The population is forced to sweat a lot. In summer it’s a common practice to safeguard oneself against the heat stroke, not only for the children but even for the adults. For decades, young children have suffering from high fever, vomiting, loose motion, dehydration, fits, altered sensorium, cough and breathlessness. There has been shortage of qualified doctors and basic rural healthcare system in the area. A majority of patients are left at the mercy of the rural medical practitioners and even quacks. The Primary Health Centres has had the usual story of paucity of doctors, and the 24 hours emergency services practically non-existent. A child getting seriously sick in a village some 20 to 40 km away, needed to be brought to the city of Muzaffarpur for medical care, that too without the prompt ambulance services over the dilapidated village roads. Until a couple years ago not a single ICU bed facility was available in Muzaffarpur for the sick children. Of the district hospital (Sadar Hospital, Muzaffarpur) , the medical college hospital (SKMCH, Muzaffarpur) and  a private maternity hospital (Kejriwal Hospital, Muzaffarpur), none were equipped to deal with seriously sick children. Only recently after a lot of media cries and the pressure from the bodies dealing with the child rights, including the State Commission for Protection of Child Rights, Bihar did the government administration woke up from the slumber and took some initiative to make the healthcare delivery system more accountable. And it is now visible also that the services have improved in last couple of years.

The teams from National Institute of Virology, Pune; Christian Medical College, Vellore; National Institute of Communicable Diseases, Delhi and various other teams from different hospitals and medical colleges like Safdurjung Hospital, Delhi and Madurai Medical College visited Muzaffarpur but could not conclusively pinpoint a cause for the illnesses or relating with litchi. It seems that the so-called researchers carried out parachuting research than any rigorous and meaningful scientific research. This became evident as they came, they saw for few days, they spoke to few persons and they went away. The basic need of the research would have been a dedicated research unit on the spot following the genuine research protocols. Anyhow, they could not isolate any evidence of a virus or other microbe, so the infection as a cause was ruled out. They were unanimous in declaring that the time lag in bringing sick children to the hospital must be shortened and relevant health education must be imparted to the villagers in a prompt manner. It was also stated that the Block Level hospitals must be made to run basic emergency services round the clock and the ambulance services should be freely available. Two things were certain. First, all the children who suffered belonged to the scheduled castes, extremely backward classes or to the minorities. Second, all the sick children if brought to a centre equipped in dealing emergencies, within six to eight hours, recovered fully merely with basic life support.

One should not derive a conclusion that the child health issue attracted attention with the publication of the report in early this year. In fact this issue has been in public imagination much before. This was the reason that the then Union Health Minister Dr Harsh Vardhan paid a visit to Muzaffarpur in the summer of 2014 and announced various relief measures including free availability of the vaccines against Japanese Encephalitis Virus (JEV).

However, it is another matter that State Government has not paid much heed, it needed. It is no wonder that the longest serving Chief Minister of Bihar, (in seat since 2005), Nitish Kumar has not once paid a visit to Muzaffarpur on this pretext, laments Dr Beer Bahadur a senior functionary of Uttar Bihar Jagran Morcha, an outfit working for the causes of North Bihar.

Looking back at the controversy, the article in the Lancet Global Health by A Shrivastava and others based on a case control study pointed towards two ingredients MCPG and Hypoglycin A in litchi, more so in the unripe fruits. They tried to substantiate in their article that litchi caused these illnesses. They postulates that malnourished children consume unripe or the rejected litchi fruits in empty stomach and go to sleep without proper meal. Their glycogen  reserve is less and the toxins super added to  some other metabolic reasons push these children to seriously low levels of blood sugar leading to impaired sensorium and convulsions.

However, there has been strong opposition to this hypothesis. The leading doctors dealing with these cases for decades, Dr Braj Mohan, Dr Arun Shah, Dr Rajeev Kumar and Dr Gopal Shankar Sahni,  opine that litchi alone is not conclusively proven to cause this illness (for their statements see box).

Dr Gopal goes on to add that this theory of litchi needs much more proof to be of any scientific importance. Dr Meghna raises certain serious questions regarding the validity of the results of this study. Two western scientists simultaneously in their article in The Lancet also raised an issue. In nutshell the report seems not to be free from a bias, and need more stringent statistical measures to be of conclusive scientific evidence.

The worse part has been the widespread media attention to this anti litchi campaign. The popular Indian media got totally carried away by this report, prominently covered this issue and almost crucified this cash crop of litchi, which has been a lifeline to thousands of thousand families of North Bihar. Rateendraji proprietor of the reputed Mukhiyaji ki Nursery, in the business of litchi grafts since 1905, feels sorry that the litchi is being been given a bad name in the name of scientific research. He perceives that this year the orchard buyers are also little reluctant fearing a slump in the market.

Now, as the summer approaches and the aroma of the pollen grains of litchi fill the ambience, it will be interesting to see how geared up the healthcare delivery system and the general administration are to deal with another season of impending outbreak of the illness.
As for now it sums up remembering what the Father of Modern Medicine Sir William Osler (1849-1919) once said, “Absolute diagnoses are unsafe, and are made at the expense of the conscience”.

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