Ninety seven children have died in the district hospital of Malkangiri in southern Odisha since September. Based on the clinical symptoms of high fever and seizures, doctors suspected the children had died of Acute Encephalitis Syndrome, or brain inflammation, caused by the Japanese Encephalitis virus.
Acute Encephalitis Syndrome is a group of conditions that affect the brain and can be triggered by a range of agents including bacterial and viral infections.
Of the 97 children, the blood samples of 77 were tested in a laboratory in the state capital Bhubaneswar. Antibodies to the Japanese Encephalitis virus were found in the blood samples of 33 children.
What about the other children who died? What had caused their deaths?
A team of researchers appointed by the state government to investigate these deaths believes they may have resulted from the consumption of anthroquinone, a toxin found in the bean-like seeds of a wild plant called bada chakunda.
At a press conference held by the Odisha health department in Bhubaneswar on November 18, the head of the team, Dr T Jacob John, emeritus professor of Christian Medical College, Vellore, explained how they had arrived at the findings.
The team observed that some of the children who had survived the bout of brain inflammation did not show signs of neurological impairment, which is common among those infected with the Japanese Encephalitis virus.
John also noticed the presence of the bada chakunda plant in the area. In 2005, while investigating an outbreak of Acute Encephalitis Syndrome that killed 175 children in Saharanpur district of Uttar Pradesh, John had isolated the toxin in the seeds of the plant. The toxin, anthroquinone, acts as a biochemical agent and causes hepatomyoencephalopathy, a medical condition where the brain is damaged.
According World Health Organisation, hepatomyoencephalopathy is one of the many conditions that fall under the broader term of Acute Encephalitis Syndrome. It also results in damage of liver and muscle cells.
In Malkangiri, his team took urine samples of five children whose blood samples did not show the presence of antibodies against Japanese encephalitis virus. The urine samples were sent to Council of Scientific and Industrial Research-Indian Institute of Toxicology Research in Lucknow. In all five cases, the samples showed the presence of the anthroquinone compound. A battery of investigations had already confirmed liver and muscle damage in the five children, who later succumbed to the disease.
For John, this was enough to confirm his hypothesis that the toxin in the bada chakunda plant was responsible for the deaths of the children who had not tested positive for Japanese encephalitis.
In his view, the district was seeing not one but “two diseases occurring as outbreaks”.
Some government doctors in Odisha and public health experts, however, are sceptical of the findings.
They point out that the team has linked the deaths to toxin consumption on the basis of just five samples. In 2012, the Regional Medical Research Centre in Bhubaneshwar had identified Japanese encephalitis virus in the blood samples of 11 children who had died from brain inflammation. Its report was labelled “inconclusive” by officials at the National Vector Borne Disease Control Program. How could a report based on five samples be taken seriously, they asked.
Dr Veena Shatrugna, former deputy director, National Institute of Nutrition, Hyderabad, said presence of the toxin in urine samples does not establish anything. “If they had looked for pesticides or any other toxin in the urine sample, they might have also found that,” she said.
Dr Mukul Das who conducted the tests at the Lucknow laboratory admitted that blood or serum is a better sample to look for the toxin, but he defended the results. “These children were so lean and thin, it was extremely difficult to draw a blood sample from them,” he said. The test which routinely takes three weeks was completed in just four-five days in the laboratory. “We usually take longer to run these tests but this was an emergency situation so we conducted the tests faster,” he said.
A senior doctor working to control the Malkangiri outbreak said three other teams had visited the district but none had investigated the dietary habits of the Adivasi community that has accounted for the bulk of the deaths. John’s team “has applied its findings from Saharanpur to Malkangiri because the same plant is found in both places”, he said. “I am not an expert in plants but there are geographical variations and inferring that the toxin killed the children just on the mere presence of the toxin in the urine sample is not good science.”
The criticism of the report isn’t limited to its findings. Public health experts have questioned the manner in which it was released by the Odisha health department. “It is an incomplete report and therefore irresponsible that it was released to the press,” said Dr Veena Shatrugna, former deputy director, National Institute of Nutrition, Hyderabad.
Local activists working with the government to control the outbreak in Malkangiri were also weary of the report. They claimed it was “a diversionary tactic of the government”.
As Scroll.in has reported, the district failed to put in place measures which could have prevented the spread of mosquitoes that transmit the Japanese encephalitis virus. The Centre and the state government also dithered over the introduction of a vaccine that could have protected children from the Japanese encephalitis.
Now the report linking the deaths to the plant toxin helps the government shift focus from its own inefficiency to the dietary and living habits of the Adivasis, said activists. “It is as simple as saying that it is a stupid community feeding poisonous seed to its own children,” said Dr Sylvia Karpagam, a public health specialist from Bangalore.
“This was useful public health information and we are not supposed to hide it,” said Dr Arun Kumar who was a part of Jacob’s team. “We can’t wait for the final proof. We are only saying that children below ten years of age should not be allowed to consume bada chakunda. We are not recommending the removal of the plant. It is a part of the biodiversity.”
Excess consumption leads to toxicity
The seeds of the bada chakunda plant are eaten routinely by the Adivasis of Malkangiri. “Children eat it raw and it is also used in dal preparation by mothers,” said Dr KK Sarkar, joint director, health department of Malkangiri. The Adivasis believe the seeds have medicinal value and administer them to children for de-worming or when they get fever, Sarkar added.
Doctors do not dispute the medicinal value of the plant.“It is used in some liver tonics available in the market,” said Vashishtha, who was the part of the team that investigated the Saharanpur deaths. “The problem is when it is consumed in excess it can lead to disease.”
He claimed that Saharanpur had a situation similar to Malkangiri. The number of deaths did not drop even after vaccination against Japanese encephalitis. “Once awareness against the consumption of the seed was done, the deaths started going down,” he said.
Sarkar said the Malkangiri administration has started an awareness campaign in the villages asking mothers to “not allow their children to eat these poisonous seeds”.
But some public health experts questioned the move. A study with five samples was not enough, they said, to establish the link between the consumption of the seeds and the child deaths in Malkangiri. Odisha government needs to first assess the toxicity levels of the seeds before asking Adivasis to stop consuming it. “The community has been consuming these seeds for years and today you say that the seeds are causing deaths,” said Dr Karpagam. “You are stopping them from eating their natural diet without having any evidence that it is the cause for the death of their children.”
Activists pointed out that the Adivasis consume the seeds partly because of the crisis of food in the area. Doctors in Malkangiri said that most of the children who died in the district hospital were malnourished. Hunger was one of the underlying causes of the deaths.
Members of John’s team did not deny the role of factors such as malnutrition. “The risk of developing the disease depends on the ratio of the [bada chakunda] seeds consumed to the body weight of the child,” said Kumar. “If the child is well nourished, he may have some bouts of vomiting and nothing severe. But a malnourished child may not be able to fight the toxin.”
He added: “After all, we all consume natural toxins and our body filters them out. It is only when the body can’t filter them out, that it leads to [organ] damage.”