Acute Encephalitis Syndrome (AES), also known as brain fever, or ‘Chamki Bukhar’ locally, is a life-threatening outbreak taking the lives of hundreds of young Indian children among the poorest regions of India. The illness attacks the central nervous system, and has killed more than 150 children this year in the Muzaffarpur district in the state of Bihar, which has become the epicentre of the crisis. With a population of almost 5 million people, Muzaffarpur has been home to 602 of the 719 AES cases reported this year alone. The rise in deaths of this particular region has revealed flaws about Bihar’s crumbling health sector, and raised concerns among citizens on the lack of attention and funding for fundamental health infrastructure across India.

Hospitals in low-income regions such as Bihar are not able to manage the influx of patients that require emergency assistance. The poorly equipped hospitals are suffering from a shortage of doctors and nurses, and lacking accessibility to necessary medicines. Doctors from all over India have flocked to Muzaffarpur to assist one of the largest public hospitals in Bihar, Sri Krishna Medical College and Hospital. The hospital has been forced to dispatch sick patients to accommodate for the surge in AES patients, and was forced to transform a ward meant for prisoners into a pediatric intensive care unit (ICU) center to make additional space. In the same hospital, there were reports of multiple children being kept in the same bed. As one of the poorest Indian states, Bihar accounts for 1,396 of the 6,000 deaths that have occurred between 2008 and 2014.

AES predominantly occurs in rural and suburban settings with seasonal outbreaks, particularly during heatwaves. Areas that have poor hygiene, water scarcity and a prevalent rodent population are most susceptible to exposure. Once detected, it must be treated promptly, or it will become life-threatening. Encephalitis primarily occurs as a viral infection; early symptoms can be similar to that of the flu, including headache, fever, muscle or joint aches and pains and major fatigue. Symptoms later worsen into swelling of the brain, confusion, drowsiness and seizures.

Children and the elderly are most vulnerable: it is reported that nearly half of all children in the region are malnourished or stunted. Malnutrition and dehydration are known to trigger low blood sugar and electrolyte imbalance, which worsens from the heatwave and humidity India is experiencing this summer.

There is still uncertainty as to what is responsible for the outbreak, however, scientists report heat waves exacerbate AES’ prevalence. A medical journal, The Lancet, published a report in 2017 suggesting that the exotic fruit, lychee, contains a toxic substance that may result in acute encephalitis syndrome when consumed. The report suggests citizens of the Bihar region, which is particularly abundant in lychee orchards, to avoid eating lychees to prevent contraction of the illness.

In order to prevent further AES diagnoses, India launched an encephalitis immunization program in 2006, which joined the National Immunization Program in 2014 to expand protection. Nevertheless, outbreaks have persisted. India’s Federal Health and Family Welfare Minister, Harsh Vardan, stated that a 100-bed pediatric intensive care unit would be built in Muzaffarpur, but there has been no update on the timeframe of its construction. In 2017, the Ministry of Health and Family Welfare along with five other government ministries, set out to implement a 660 million dollar comprehensive plan that would focus on the expansion of japanese encephalitis vaccinations, medical and social rehabilitation, improved nutrition and public health interventions.

The growing death toll is drawing anger amongst parents of the Bihar state and fear across India. As the situation worsens, citizens are demanding greater focus on public health. Local initiatives include implementing house-to-house outreach programs to preemptively test children for AES and treat the diagnosed swiftly to mitigate overcrowding hospitals. The fundamental levels of health infrastructure such as accessible, and properly equipped hospitals are missing; travels to the nearest hospital could take up to four hours, and often by that time children are in a life-threatening position and it is too late to help. Data made available by the Ministry of Health and Family Welfare displayed that about 79.5% of the 1,719 villages do not have a public healthcare facility.

The inability to supply primary health care displays the struggling health infrastructure within the rural areas of India. While the federal government spends less than 1% of annual GDP on health, the government health spending in Bihar is the lowest among Indian states. Greater investment in the public health sector is necessary to alleviate the current crisis and to prevent itself as a future threat to the developing region.

While there is no conclusive evidence as to what is causing this outbreak, citizens of the area are strongly recommended to avoid lychee consumption and ensure an evening meal, however, malnutrition remains a major crisis that must be addressed by state and federal governments to mitigate the contraction of this life-threatening illness.