Over 100 children have died of Acute Encephalitis Syndrome in Bihar
The smallest coffins are the heaviest and that is the impression one gets when stepping inside the premises of the Shri Krishna Medical College and Hospital (SKMCH) in Uttar Pradesh's Muzaffarpur, which has witnessed the deaths of close to 100 children in three weeks.
Passing through the wards, which seem overcrowded even by the standards of government-run hospitals, the awkward silence is pierced every few hours by wailing women clutching onto the body of their children.
Other parents look on in fear, praying they be spared such a tragedy. Doctors and paramedics appear exhausted, their eyes blurred as they toughen themselves up to assist those still battling on to live.
Besides SKMCH, patients with Acute Encephalitis Syndrome (AES) are being admitted to the privately-owned Kejriwal hospital in Muzaffarpur.
But it is SKMCH which has accounted for most of the deaths so far - 96, out of a total of 113. It is SKMCH where most children afflicted with AES are being brought to for treatment.
The Bihar government has announced it would reimburse expenses incurred towards treatment and hiring of ambulances etc.
Medical opinion remains divided over the causes that led to the AES outbreak, which is said to have been tormenting this north Bihar district and adjoining ones for several years and has acquired epidemic proportions this time.
Gopal Shankar Sahni, the head of pediatrics department at SKMCH, says many people are wrongly attributing the outbreak to consumption of litchis. "I have been witnessing this phenomenon for many years and it is caused by excessive heat and humidity," he says.
The theory is, however, debunked by independent child specialist Arun Shah, who formerly headed the Bihar chapter of Indian Association of Pediatrics and was closely associated with a study conducted in 2016 by Vellore-based epidemiologist T Jacob John.
The study first highlighted the consumption of unripe litchis as a contributory factor for hypoglycemia - extremely low levels of blood sugar - which has been blamed for most of the casualties this year.
If heat and humidity is the main contributory factor, why is it that most children develop the symptoms early in the morning, asked Mr Shah.
"Our study never said anybody who consumes litchi will fall ill. The unripe fruit contains a high concentration of the toxin called MCPG which triggers hypoglycemia if consumed by a child with a malnourished body. Therein lies the answer to the question: why only the poorest of the poor and mostly those living in Muzaffarpur and adjoining districts are suffering from the disease," he told PTI.
Raw litchi, which tastes bad and is not fit for sale, is often consumed by poor children in need to fill their empty stomachs. Litchi trees abound in Muzaffarpur and adjoining districts and the fruit, in its unripe form, can be accessed by any child in these areas from trees or ground, fallen due to storms, Arun Shah said.
Children from better-off families are less likely to suffer from malnutrition and there is very low probability of them being allowed to eat raw litchi and that too on an empty stomach by their guardians. Ripe litchi, whether plucked directly from a tree or purchased, does contain MCPG but the concentration is much less and, hence, less likely to cause hypoglycemia, he added.
"Let me point out that our study was not the only one to have come out with such a conclusion. Our findings were corroborated by a research conducted by the Atlanta-based Centre for Disease Control and Prevention (CDC) which was published in the reputed journal Lancet," Mr Shah said.
He also pointed out that their study had made a number of recommendations to prevent an AES outbreak. This included raising awareness, so that children were not allowed to go to bed hungry and prevented from entering litchi orchards.
In addition, the need to eradicate malnutrition which leads to many complications over a lifetime, was underscored though it is a long-term project.
The awareness drive was conducted well in 2017 and 2018 and the incidence was much lower during those years. This year, as in 2014, all those responsible for primary healthcare were perhaps involved in the Lok Sabha election work. "As a result, the awareness drive was slack and we are facing the consequences," he alleged.
Mr Shah also asserted that the government needed to spruce up its healthcare system at the level of PHCs to avert such tragedies.
"Look, not all children suffering from hypoglycemia live close to SKMCH. Many of them come from more than 100 kilometres away. Now, a child with even nil blood sugar can be saved if glucose is administered within four hours of the onset of fever and convulsions. But the time taken up in travel often leads to children reaching hospitals when it is too late.
"Transfusion of glucose is not a big deal and it must be ensured that all PHCs and CHCs are equipped with these. Otherwise hospitals will never be able to cope, no matter how many beds are added or how many additional doctors are deployed," he added.
Many people who had brought their AES-afflicted children to SKMCH said they had to travel 50-100 kilometres since local health professionals said "paani chadhana padega" (glucose needs to be administered) but it was not available.
Above all, Mr Shah said, it must be kept in mind that this is a disease that is best prevented, "since even those who are discharged after treatment may develop several complications because of the inflammation of the brain."