NEW DELHI - The death of 157 children at Muzaffarpur in the central state of Bihar has brought the focus on how poor children remain undernourished in India, a country which in spite of fast-paced economic growth continues to face a malnutrition crisis.
A team of the Indian Medical Association found that malnutrition "contributed substantially" to the children dying from Acute Encephalitis Syndrome (AES).
While experts remain divided on the trigger for the AES or even if the cause of death was AES, they are sure that malnutrition remains a key factor as all the victims were from impoverished rural backgrounds with 70 per cent of the victims under the age of five.
"Bihar state in general is the worst for under-five malnutrition. It has been going on for some time. It is socially accepted as it's a normalisation of deviants," said Dr T. Jacob John, a virologist who led a team doing research on child deaths in Muzaffarpur a few years ago. Every year, children die in Muzaffarpur from the same symptoms, with 11 deaths in 2017 and 90 fatalities in 2014.
This year, some experts believe, the fatalities were also higher due to a heatwave and failure to implement properly government nutritional programmes, including providing healthy meals in government schools.
"Prevention in the short term is very simple. Feed the child before the child goes to sleep. A good meal so the child won't go into hypoglycemia. That would have prevented the disease in the short term. Once disease occurs, it can be treated very easily. You need to do two things, blood sugar has to be kept up and fatty acid oxidation turned off," said Dr John.
His research indicated the year-on-year fatalities were caused by encephalopathy, a treatable biochemical disease triggered by consumption of lychees, grown in abundance in Muzzafarpur. He found a toxin in the fruit when combined with malnutrition and the lack of a proper meal leads to a drop in sugar levels and disrupts the oxidation of fatty acids or enzymes that break down fats in the body.
Dr Arun Kumar Shah, a pediatrician in Muzaffarpur, said: "Children from better-off families in the villages or from the town who take meals at least twice a day haven't suffered from this disease in the last 25 years."
Prime Minister Narendra Modi told Parliament last Wednesday (June 26) the deaths were "unfortunate and a matter of shame for us".
In spite of fast-paced economic growth over the last two decades, India has a malnutrition crisis with the highest number of children affected by it in the world.
Forty-three per cent of Indian children under five years old are underweight or one in three children, according to estimates.
India accounts for almost a third of the world's cases of stunting, a measure of malnutrition described by the World Health Organisation as the impaired growth and development that children experience from poor nutrition and repeated infection, among other factors.
India has 46.6 million children who are stunted, followed by Nigeria with 13.9 million and Pakistan with 10.7 million, according to the Global Nutrition Level.
And within India, the central state of Bihar, which is among India's poorest states, has among the highest rates of malnutrition. The National Family Health Survey, an Indian government survey, showed that almost 48 per cent of children under five in the state were stunted in growth, which is among the highest for India.
"Bihar is among the top three states in child malnutrition, as measured by stunting. Muzaffarpur child malnutrition indicators are similar to the state average. The occurrence of child deaths due to epidemics like encephalitis are symptomatic of a poor public health system, which includes inadequate access to proper nutrition for mothers and children, unsatisfactory maternal and child health services and poor sanitation, apart from the pervasive issue of poverty and low incomes that deny access to good nutrition and health care," said Mr V. Ramani, a retired bureaucrat who specialises in nutrition issues.
The other two states are Jharkhand and Madhya Pradesh, which are also in central India.
In India, the problem of malnutrition starts from pregnancy with little awareness among poorer families, who usually don't have the means, about taking supplements or eating right during pregnancy or even after the child is born. The problem is further aggravated by early marriages with younger mothers also likely to have complications during childbirth.
Government statistics show that 47 per cent of women aged between 20 and 24 were married by 18 years of age.
"Malnourishment is starting from the womb. It's a hostile environment for female children in particular," said Dr Kafeel Khan, who was in charge of the encephalitis ward at BRD Medical College in Gorakhpur, Uttar Pradesh, where 70 children died two years ago. Dr Khan was jailed but released in 2018 after it was found that the children died because of a government failure to provide oxygen cylinders.
"It's a vicious circle," he said. Dr Khan, a right-to-health activist, who was in Muzaffarpur helping with patients, said two children had died on Wednesday.
The government has schemes for boosting mother and child nutrition, children are provided midday meals consisting of basic foods such as lentils and rice in government schools and under various other schemes.
But implementation depends on local efforts and varies from area to area.
"What is needed is a significant improvement in both maternal and child care services, both on the healthcare and ICDS (Integrated Child Development Services) fronts, and far more effective convergence between these two departments and others like water supply and sanitation," said Mr Ramani.
"A focus on improved service delivery and increased public investments in these sectors is essential to improve long-term prospects for mothers and children."