IMB 795

LITCHI, THE UNLUCKY FRUIT: WHAT DOES THE

EVIDENCE SAY?

G RAMESH AND STUTI GOSWAMI

G Ramesh, Professor of Public Policy and Stuti Goswami, prepared this case for class discussion. This case is not intended to serve as an
endorsement, source of primary data, or to show effective or inefficient handling of decision or business processes.

Copyright © 2020 by the Indian Institute of Management Bangalore. No part of the publication may be reproduced or
transmitted in any form or by any means – electronic, mechanical, photocopying, recording, or otherwise (including internet) –
without the permission of Indian Institute of Management Bangalore.

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

INTRODUCTION

“Dangerous Fruit: Mystery of Deadly Outbreaks in India Is Solved” claimed The New York Times in
January 2017 (Barry, 2017). Similarly, the Times of India wrote, “the mystery behind the outbreak of an
unexplained neurological illness in Bihar’s Muzaffarpur, which had claimed nearly 100 lives each year
till 2014, has been solved” (Jha, 2017). Every year, some children after eating litchi fruit were falling
sick, developing fatal seizures and convulsions from what was initially diagnosed as Acute Encephalitis
Syndrome (AES). The cause of death of the children was attributed to them eating litchi after skipping
dinner. They had developed ‘Hypoglycemia’ due to a sudden drop in sugar level. The recommended
remedy was that they should be administered dextrose for an immediate cure. Children should be
educated about the danger of eating litchi when they are hungry.

Ideally, the medical discovery should have resolved the mystery and the government should have led a
remedial programme for the children. However, though the incidences decreased, they continued to haunt
before rearing up again in 2019 with about 125 deaths. The controversy around the possible causes
continued to simmer. Every stakeholder’s concern was that litchi should be saved from the disrepute lest
it affected its growers and the local lobby was especially keen on deflecting it away from litchi. They
cited research which said that it could be due to pesticide residual, and physicians stated that it could be
due to a virus. In spite of the clamour for evidence-based policy making in policy literature, the
recognition of the evidence and consensus on the remedy themselves seem to be elusive and time-
consuming. Even if the evidence was accepted, the policymakers and administrators were faced with the
challenge of implementing it through the healthcare system and communicating the cause of the disease
and its associated risk to parents. During the litchi season, the fruits were lying all over the fields in the
villages. Controlling hungry children from eating litchi was an uphill task. The attraction of the fruit and
the complexity surrounding the remedy were its undoing.

LITCHI, THE UNLUCKY FRUIT

Bihar has been the largest litchi producing state in North India and one of its districts, Muzaffarpur,
contributes 40% to the share of production. Bihar produced 300,000 MT of fruit cultivated from 32,000
ha (Begg, 2019). Shahi Litchi, one of its varieties received Geographical Indication (GI) tag in 2018.
However, its appeal was marred by the abnormal number of mysterious deaths surrounding it since the
mid-1990s. In 2014 alone, more than 200 children were reported dead due to a “mysterious” illness after
consuming the fruit. These deaths occurred right before the monsoons, that is, the litchi season. It left
several litchi growing villages distraught, especially as the families of the children could not comprehend
how their child who seemed perfectly healthy collapsed suddenly. The parents were shocked and horrified
as most of the children who were healthy hours before, went into comatose condition immediately on
reaching the hospital and died soon after. The doctors were at a loss in diagnosing the cause of the deaths.
Most of the children arrived at the hospitals in the night with acute neurological symptoms like swelling
of the brain, seizures and convulsions, although strangely they seemed to have been healthy moments
before that. The symptoms shown by the sick children were similar to those of Acute Encephalitis
Syndrome (AES) prevalent in the region. In local parlance, parents and health workers called it Chamki
bukar which means seizures. Litchi was soon surrounded by the enigmatic mystery around this killer

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

disease and several hypotheses were floated around. It entered the radar again in 2019 when more than
125 children died from this disease (Figure 1). There were similar instances of children’s deaths in Malda
District in West Bengal in 2014 (NDTV Food, 2014) and in Bangladesh which were more sporadic
(Jayaraman, 2017).

LITCHI IN INDIA

Litchi is a seasonal fruit and is said to have originated thousands of years ago in China. It entered India in
the 18th century via Myanmar and since then it has been a seasonal delight throughout the country (Singh
and Babita, 2002). Litchi grows in the sub-tropical regions and requires specific climatic conditions. It
thrives well in the temperature range of 10-38⁰C and requires moist atmosphere with sporadic rainfall,
hot, wind-free summers and frost-free winters (Singh and Babita, 2002). Well-drained, loamy soil, rich in
organic matter is needed for its cultivation. The specific climatic requirements of the plant make it
cultivable only in select countries. The litchi is a slow-growing, evergreen tree which bears fruits either in
the shape of a round or a heart. A spiky-leathery skin, which is usually pinkish in colour, covers the fruit
and the edible part of it, the aril, is translucent, fleshy and juicy. At the core of the fruit is the dark-brown
coloured, hard seed; a smaller seed is usually preferred for commercial purpose.

According to the National Horticulture Board of India, China has been the largest producer of litchi
followed by India. India and China together account for 91% of the total litchi production in the world.
Other countries that produce litchi are South Africa, Madagascar, Australia, and Brazil. The Agricultural
and Processed Food Products Export Development Authority (APEDA) of India mentions that because of
its specific climatic requirements, litchi is primarily produced in the states of Bihar, West Bengal, Assam,
and Jharkhand. By 2011, litchi was cultivated in 72 thousand hectares of land, from all states, with the
total production at 497 thousand tons (Table 1). The area under litchi cultivation grew to about 92
thousand hectares and the total production to 583 thousand tons in 2016-2017, which is a demonstration
of its popularity (Government of India, 2017).

Muzaffarpur district in Bihar has been famous for the Shahi variety of litchi which has a unique rose
aroma and bears high-quality fruit. There are several other varieties of litchi depending on the shape,
color of the plant’s leaves and the skin, scent and taste of the fruit. Some of the varieties are – Shahi,
China, Bedana, Ajhauli, Bombai, Dehra Dun, Gulabi, Ellaichi, Longia, etc. Litchi produced in India has
been mostly consumed domestically, with only a meager quantity being exported to the Gulf countries.
However, there has been a high demand for litchi, especially in European countries, which India has not
been able to penetrate. This fruit is a highly perishable good. Being a delicate and temperature-sensitive
fruit, its marketing needs are to be done in the harvesting season itself and in a temperature-controlled
environment. For increasing the marketability of the fruit, appropriate process technology and cold
storages are required. Litchi is available only for a limited period in the year, thus making it more
desirable. APEDA, the Apex export facilitating body, was trying to improve the export scenario of litchi
by enhancing infrastructure efficiency (Table 2). Amidst all this, a major concern for growers and
exporters is that this kind of controversy can hamper its market potential.

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

A DELICACY WITH NUTRITIONAL VALUE

Litchi has huge market potential. It is used as a flavor in manufacturing of ice cream, juice, syrup, and has
been being tried for winemaking also. A new initiative of litchi-flavoured wine was being taken up by
some beverage giants, which was expected to boost its preference with the wine-industry (Hindustan
Times, 2010). Due to its highly perishable nature, canned litchi is used as a method to increase the
longevity of the fruit. Canned litchi can be stored throughout the year and is used for different culinary
delights like ice cream, custards, lemonades, and iced tea.

Litchi is considered to have many health benefits. Some of which are mentioned in ancient Chinese texts
and in the Ayurveda as well. It is high in Vitamin C which helps the human body to develop immunity
and fight against infections and cold. Apart from Vitamin C, this fruit provides various other nutritional
values like carbohydrates, fats, proteins, etc. (Appendix A). Other benefits include improving digesting
and mitigating heartburns. It has a high content of polyphenols which helps in reducing the chances of
coronary heart diseases, thereby maintaining a healthy heart.

The presence of flavonoids in litchi lends it anti-cancer properties, while the abundance of phosphorus
and magnesium in the fruit helps to maintain healthy bones. The seed of the fruit is dried and used as a
medicine for diarrhoea in some parts of India (Sinha, 2015). Sadly, the positive aspects of litchi have not
been communicated and acknowledged by the users.

THE “DIAGNOSIS” OF THE MYSTERY

Shrivastava et al. (2017) published a report in the Lancet Global Health that the “mystery” behind the
tragic deaths in Muzaffarpur was resolved and that the cause was consumption of litchis. A case-control
study in two hospitals of Muzaffarpur was carried out by a joint team from the National Centre for
Disease Control, India and Center for Disease Control and Prevention, USA in 2014. They studied 390
patients with similar symptoms of neurological issues like brain swelling and seizures which were
brought for treatment in these two hospitals, out of whom 122 subsequently died. It was found out that
litchi seed contains methylene-cyclo-propyl-glycine (MCPG) and hypoglycin A which reduces the body’s
ability to produce glucose, resulting in low sugar levels or hypoglycemia. In the instance of unripe litchis,
the level of MCPG is even higher. Most of the children who succumbed to this “mysterious” disease were
found to have skipped dinner after eating litchis, which is believed to have triggered the response and
aggravated the reaction. These children also had abnormally low blood glucose levels, which increased
their chances of acquiring AES. The report stated:

Our investigation suggests an outbreak of acute encephalopathy in Muzaffarpur

associated with both hypoglycin A and MCPG toxicity.

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

It further mentioned:

To prevent illness and reduce mortality in the region, we recommended minimizing litchi
consumption, ensuring receipt of an evening meal and implementing rapid glucose
correction for suspected illness. (Shrivastava et al., 2017)

Findings similar to the Lancet report were already published in the Indian journal Current Science in
2014 by a team of scientists led by Dr. Jacob T John, an epidemiologist in the Christian Medical College
(Vellore, India) (John and Das, 2014). The paper by John and his colleagues observed that there were no
traces of virus found in the patients that could be attributed as the cause of the illness and that the patients
had low blood glucose levels when they were brought to the hospital for treatment. The paper also
mentioned presence of hypoglycin A and MCPG toxins in the litchi fruit. The research team even
contended that the disease was not at all encephalitis but encephalopathy. According to Medicinet:

Encephalopathy is a term that means brain disease, damage, or malfunction.

Encephalopathy can present a very broad spectrum of symptoms that range from mild,
such as some memory loss or subtle personality changes, to severe, such
as dementia, seizures, coma, or death.

John’s response to our queries can be seen in Appendix B.

After the Lancet report was published, John contended:

They quote our study but don’t honestly say what we have found. If they did that then
they can’t claim originality. They have done a large case-control study but borrowed all
important information connected with the illness from us. (Prasad, 2017 (A))

Later, Lancet reportedly contacted him to get a complete picture of the research. Speaking on this, John
said:
It is very decent of Lancet to have got in touch with us and seek our clarification on this
issue. That shows Lancet is careful of its credibility, careful that any such issue is
immediately sorted out. I admire Lancet. This is what we want from every publisher,
every investigator and every paper” (Prasad, 2017 (B)).

Srikanthiah of the Center for Disease Control and Prevention countered John’s claim about the originality
of the study and mentioned:

There are a few key findings in our study that have not been, to our knowledge, reported
previously. First is the evidence of the metabolites of hypoglycin A and MCPG in the
specimens of affected children, and the demonstrated metabolic abnormalities that
resulted due to the effects of these toxins. Second is the statistically significant
epidemiological association between illness and litchi consumption, as well as the
modifying effect of the absence of an evening meal. (Prasad, 2017 (C))

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

RECOMMENDATIONS BY THE EXPERTS

The findings published in Lancet and the research report by John’s team was tentatively accepted as the
diagnosis of the “mysterious” disease. There was a general acceptance of the findings of the cause of the
disease and treatment procedure. John opined in his interview that the government has also accepted the
diagnosis and had suggested a treatment protocol (Appendix B).

Based on their findings, John and his team recommended to the Bihar government to intervene by raising
awareness among parents to limit or restrict the consumption of litchi by their children and ensure that no
children go to sleep without dinner. During the study, John and other doctors were able to save 74% of
the children who tested for extremely low blood glucose level, by infusing 10% dextrose within 4 hours
of hospitalization. The vital recommendation from the team was the immediate infusion of 10% dextrose
to the hospitalized children with extremely low blood glucose level. He mentioned in our interview that
the physicians who administered this treatment described the protocol as ‘miracle cure’.

The Lancet paper made recommendations on similar lines. They said:

Our data supports a public health recommendation – minimising litchi consumption,

eating evening meal throughout the outbreak period and implementing rapid glucose
correction for suspected illness. These recommendations are specific to children in
Muzaffarpur. (Prasad, 2017 (C))

EVIDENCE MIRED IN CONTROVERSY

The fruit, mysterious as it is, was mired in controversies about it being the cause for deaths. The children
still reported with these symptoms and uncertainty still persisted in the minds of the people regarding the
cause of deaths. A similar dilemma was prevalent when mad cow disease was detected in the United
Kingdom, wherein people were worried about eating beef and the government was in dilemma over
banning beef (Appendix C). The litchi disease subsided after some years but reappeared again in 2019,
leading to fresh furore and debates. The Union Government intervened and the Union Health Minister,
Harsh Vardhan, decided to establish a branch of the National Institute of Virology in Muzaffarpur. The
Minister, a medical professional himself, announced a slew of measures and gave directions for
improving the medical facilities and infrastructure in the region. The Minister set up a high-level
multidisciplinary team with a purpose:

To establish the cause of the disease, there is an urgent need for an inter-disciplinary,
high-quality research team. The research team shall work with the children suffering from
AES/JE looking at various aspects including periodicity, cycle of disease, environmental
factors and metrological data, besides other factors. (Kaur, 2019)

The Bihar government designated the Patna-based Indira Gandhi Institute of Medical Sciences (IGIMS)
as the Nodal Centre for research on the disease along with a Virology lab (Kaur, 2019).

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

In the midst of controversies about the findings, a study was published in The American Journal of
Tropical Medicine and Hygiene in July 2017. The report claimed that agrochemicals and not litchi, was
responsible for the sudden neurological illness of the children, followed by death in many cases (Islam et
al., 2017). One of the pesticides that was banned in many countries – Endosulfan – was found to be used
in the litchi farms in Muzaffarpur and the exposure of the children to this and other agrochemicals was
supposed to have resulted in the mortality of the children. An earlier study on a similar outbreak of AES
(though in a small number as compared to that in India) carried out by a team of US-Bangladesh
researchers suggested that there was a “strong association” between the areas where the agrochemicals
were used and the cases of AES.

This repetitive annual seasonal crisis triggered many hypotheses – unknown virus, pesticides applied in
the litchi farms, toxins in unripe litchis, etc. as possible explanations for the unexpected deaths at such
regularity. The contention of the growers was that even 6-month-old babies were affected by these
symptoms and they were unlikely to have consumed the fruit. Litchi was grown in other areas also; so
why was there a preponderance of this disease only in Muzaffarabad? Initially, it was thought to be the
deadly Japanese Encephalitis, but further research did not confirm it. In the scientific community, experts
like Rahman at the Calcutta School of Tropical Medicine (CSTM) propounded the view that it could be
due to a virus (IANS, 2014). It even started getting political traction, and an opposition party leader in
West Bengal, Surjya Kanta Mishra said:

Such a case was reported when we were in power but we soon learnt that it was caused
due to pesticides applied on stalks of litchi trees. But now we are getting some new
information. After the incidents were reported earlier this month, it was said some virus
was responsible. Now, today we were told it is due to the presence of a toxin in unripe
litchis. I appeal to the government to take expert opinion so we can ascertain the reason
behind this tragedy. (NDTV Food, 2014)

The local medical professionals were not happy with the process followed by the CDC researchers.
Dikshit, Vice President of India Medical Association of Bihar opined:

Be it CDC or NCDC or NIV, they work on an ad-hoc basis on AES. They can’t work
round the year and round the clock on it as they have other subjects to work upon.

According to an expert quoted by Down to Earth, the State lost 5 years since 2014.

We could have used that time to at least work in the direction of finding a cause.
Unfortunately, nothing has taken off till date…A lab at the local level would have worked
round the clock to find out the cause of the syndrome. Also, the wisdom of doctors in Sri
Krishna Medical College and Hospital (SKMCH), who have spent their lives treating
children suffering from AES and repeatedly deny that litchi is the main culprit, would
have come handy had there been a lab in Muzaffarpur. (Kaur, 2019)

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

The growers and traders were worried about the impact on litchi market and were trying to absolve litchi
of any blame. Their contention also finds its voice in Dr Nath, a scientist with the National Research
Center for Litchi. According to him, it is misleading to blame litchis for the deaths. He opines that all the
children are from the economically weaker section and incidents could be due to malnutrition and
hygiene. His views can be seen in Box 1.

Box 1. Interview with Dr Nath

Director of the National Research Centre for Litchi (NRCL)

An ardent supporter of litchi, Dr. Nath says: “it has not been proved that deaths
happened due to eating litchis. It could be happening from people eating raw fruit as it
is highly acidic. The affected children are always from poor families and never from
affluent families – so litchi cannot be blamed for this”. According to him, the deaths
are reported even during non-litchi seasons. There have been cases of 6-month-old
babies dying and this could not be due to litchis. “If it was such a dangerous fruit”, his
contention was, “how did it get the GI Tag? It has, in fact, high medicinal qualities”.
According to him, the state government has still not accepted the diagnosis of litchi.

ECONOMIC IMPACT

Even though litchi growing is concentrated in a few districts, any adverse news about the fruit could
impact thousands of farmers. For example, in June 2015, right after one of the major outbreaks in
Muzaffarpur which claimed over 70 lives of children, the litchi business underwent a major slump.
Thakur, the managing director of Litchika International told a news channel (News18):

We have witnessed nearly 40 per cent decline in the sale of litchis in the last three days
after it was reported that AES has some connection with this sweet and juicy summer
fruit.

The litchi scare resulted in a drastic fall in demand from the wholesale market, which eventually led to a
severe drop in the price of the fruit. This triggered its own controversy. Amidst this crisis, a litchi trader,
Kedia, accused the mango growers of spreading rumors about toxic litchis. He said:

I strongly feel that people in Tamil Nadu and Andhra Pradesh prefer litchi. So, the mango
growers must have conspired by defaming litchi. (IANS, 2014)

One such person who believed litchi was not to be blamed was Singh (see Box 2), the President of the
Litchi Growers Association of India. According to him, the deaths were not due to litchi because the
deaths happened even during the offseason of litchi.

Negative rumors seriously threatened the very survival of these farmers, as most of the farmers in India
are marginal farmers and their subsistence solely depends on their ability to sell their produce. There was
pressure on institutions concerned with the crisis to come up with a solution and clarify if it was safe to

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

consume litchi. It was felt that diagnosing the cause of deaths could help restore the reputation of litchi
and avoid the loss of consumer trust every time there were reports of deaths from eating litchi. There was
an urgent need to assure the consumers and the farmers about its safety.

Box 2. Interview with BP Singh

According to him, death due to litchi was a myth. The litchi growing period is less
than 3 months. In Bihar, it starts from 20 May and goes through June; and in West
Bengal, this period starts in early May. But the deaths are reported even in other
months. It is also reported from districts where litchi is not grown. He feels it could
also be due to pesticides, as one research report mentioned. This is because of the
farmer’s lack of knowledge on pesticide usage, about which the government is doing
nothing. He blames the government for not taking up any campaign for curbing the
rumors about the ill effect of Litchi. The rumors have definitely affected the market
for litchi. In fact, he feels climate change has had more serious effect on production. In
his opinion, climate change may also contribute to its poor production. The season’s
temperature in Bihar has increased from 40 degrees to 42-43⁰C in recent years. It can
impact Litchi, which is a fragile and sensitive plant.

COMMUNICATING EVIDENCE

The disease was mired in controversy regarding the diagnosis of the cause, though the remedy of
administering dextrose to the patients seemed to be working. There was a conflict in the scientific
community itself. So far, there were only two research reports. Ideally, there should have been
more research. It was felt that the loss of these precious 5 years due to delay in the diagnosis had
put the system in a state of a lull. The government decided to proceed on the basis of the studies
and formulated comprehensive programs to implement the recommendations. A bigger challenge
for the state government was in communicating the findings to various stakeholders – about the
disease, treatment, its risks, and preventive measures.

The different findings in disease controls often create complexities for the government in framing the
policies. The government would ideally need convincing proof and broad-based consensus before
committing itself to a policy. However, it cannot wait because the lives of vulnerable children are at stake.
When, Vishal Nath, the Director of the National Research Centre for Litchi (NRCL), was asked in an
interview in 2015 about the impact of reports on AES on litchi and litchi farmers. Nath replied:

It is a matter of great concern. As a researcher, I do not rule out that litchi can cause AES.
But there should be scientific evidence. The media should be careful with its reportage.
Litchi business was at stake this year because of these unconfirmed reports. Fortunately,
it did not translate into losses. But the situation might worsen if the links are not
disproved at the earliest. Farmers are also concerned. Many victims of AES are children
of these farmers. They are equally worried that the crop they cultivate could kill children.
(Pandey, 2015)

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

The government was faced with these challenges even after the diagnosis of the disease. The issue was
quite critical because it involved both the livelihood of the farmers and the lives of innocent children.
There was increasing demand for a definitive cause and solution. The government could not categorically
declare the fruit to be safe as children were still exposed to its side effects.

The first step was to obtain the buying-in for the diagnosis and remedy from the professional community.
The government conducted training programs and standardized the treatment procedure. They had to
focus on doctors from public as well as private systems. The doctors were asked to look for symptoms of
hypoglycemia and treat the children on emergency footing once a child was admitted. The suggested
remedy was simple, but parents often brought their children to the hospitals after the situation got
complicated. Also, the disease itself seems to progress fast once it set in. There were still fatalities. The
government suddenly found itself in the midst of a serious problem of epidemic proportion when it
returned in 2019 and lacked a coherent comprehensive strategy to address the problem. The government
finally showed some earnestness when the disease increased in its intensity and announced a series of
measures to control the disease. It deployed more professional resources and drug supplies in the district.
The Union Government also announced a set of measures to mitigate the problem, as mentioned earlier. It
also sent a team of medical professionals to support the State and set up a high-level professional
committee for investigation. Surveillance was increased and tracking at village level where incidences
were high was introduced.

Communicating to the stakeholders throughout the length and breadth of the State was a big challenge.
There were fundamentally two categories of stakeholders or interested parties. One set was the care
providers which included policymakers, administrators, physicians, hospitals, nursing homes, the NGOs,
etc. The second set of stakeholders included parents, children, growers, traders, and finally the general
public. Regarding the first set of stakeholders, there was a need for consensus building among
policymakers and administrators, medical fraternity, and NGOs about the severity of the problem,
diagnosis of the disease, and treatment protocol. At the end of 5 years of implementation of the findings,
the policymakers, scientists, and medical professionals were still discussing further research and possible
causes. With convincing evidence of the diagnosis still pending, they accepted the findings and started
implementing the policy. The government provided extensive training programmes to medical
professionals and health workers. John’s team helped deliver these programs. The training program was
conceptualized, and sensitization was conducted for doctors and health workers across hospitals in the
three states of Bihar, West Bengal, and Uttar Pradesh. The situation showed improvement until the
epidemic struck again in 2019. However, the healthcare infrastructure still lagged behind in the instance
of laboratories, beds, and infrastructure. This also contributed to its lukewarm implementation.

Even more challenging was the task of informing the general public and parents of vulnerable children to
be cautious about the litchi eating habit of their children and about skipping dinner after eating the fruit.
This was a complex task as this had to be communicated to all parents of the state. The program had to
be repeated every year as a new cohort of children would reach that age when they became susceptible to
contacting the disease which parents tend to ignore. It needed continued reinforcement. There would be
many ignorant parents or innocent children consuming litchi with abandon. The parents could typically
underestimate the risks. The exposed children were of a very young age and they may not appreciate the

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

warnings. Also, in disseminating the information, it was important the messages did not spread panic
among the general public. Communicating the symptoms and cause of deaths without panicking them, but
at the same time without diluting the risk perception was a delicate task. The messages had to be crafted
and articulated well. The government conceived a major initiative for communicating with health workers
and farmers about the nature of the disease. It conducted campaigns in the affected villages to sensitize
the villagers. They also visited the affected villages and spread the message. They also tracked these
villages. On the contrary, there was a constant stream of messages trying to absolve the fruit of this blame
and divert the ill-attention. In trying to save litchi from this disrepute, they achieved the
counterproductive goal of aggravating the problem and delaying the resolution. Alternate narratives of the
disease were diluting the messages.

The government also took care to protect the growers and addressed their concerns with the provision of
technology, cold storage, and market promotion. In spite of this, the growers still took a hit in sales and
price realization. However, the government did not take any initiative to promote the positive aspects of
the fruit and dilute the negative publicity.

THE POLICY CHALLENGES

The state government received some comfort from the research findings, but it still had to grapple with
many challenges. Though there were alternative research findings and opinions about the cause of the
deaths between hypoglycemia and presence of pesticide, the first option was felt to be most probable.
According to John (Appendix A), even the treatment administered validated the findings. Different
opinions continued to be in vogue among stakeholders. Though the incidence of deaths came down with
the interventions undertaken by the government, the disease continued to impact. The government was
concerned with communicating it across the length and breadth of the state among the medical
professionals as well as general public. It was concerned about quickly arresting the incidence of the
disease, and creating awareness among the general public and the vulnerable sections. It was also
concerned about the litchi market and did not want it to suffer in the process. However, the fruit still
carried the stigma and the stakeholders were grappling with it.

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

Figure 1
Children showing symptoms of Acute Encephalitis Syndrome (AES) being treated
at a hospital in Muzaffarpur district on June 19, 2019

Source: Nadimpally and Fatima, 2019

Figure 2
Litchi Fruit

Source: The Huffington Post, 2017

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

Table 1
All-India area, production and productivity of Litchi

Year Litchi
Area (‘000 Production
Ha) (‘000 MT)
2008-09 72.0 423.0
2009-10 74.4 483
2010-11 78.0 497.0
2011-12 80.4 538.1
2012-13 82.7 580.1
2013-14 84.2 585.3
2014-15 85.0 528.3
2015-16 90.1 558.8
2016-17 92.1 583.4
(Provisional)

Source: Government of India, 2017

Table 2
Export of Litchi from India

Quantity in MT
Value in Rs. Lac

2014-15 2015-16 2016-17

Country
Qty Rs. Lacs Qty Rs. Lacs Qty Rs. Lacs

UAE 0.03 0.01 0.03 0.02 20.37 52.68

Nepal 44.6 17.73 9.4 3.84 53.96 30.77

Thailand 0 0 0 0 50 20.93

Kuwait 0.09 0.09 0.12 0.3 0.33 0.46

Bangladesh 915 163.8 0 0 0 0

Others 1.63 33.35 0.12 0.05 0 0

Source: Government of India, 2017

Note: 1$ = Rs. 71.81, approx. in November2019; 1 lac = 0.1 million

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

APPENDIX A

Nutritional Composition of Litchi

Nutritional Composition Content (per 100 g litchi pulp)

Energy 66 kcal
Protein 0.83 g
Fat 0.44 g
Carbohydrate 16.53 g
Fiber 1.30 g
Thiamin 0.011 mg
Riboflavin 0.065 mg
Niacin 0.603 mg
Vitamin B6 0.10 mg
Vitamin C 71.5 mg
Vitamin E 0.07 mg
Vitamin K 0.40 µg
Folate 14.00 µg
Calcium 5.00 mg
Iron 0.31 mg
Magnesium 10.00 mg
Phosphorus 31.00 mg
Potassium 171.00 mg
Zinc 0.07 mg
Sodium 1.00 mg

Source: Nath, 2016

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

APPENDIX B

Interview with Dr. Jacob T John, CMC, Vellore

The annually recurrent seasonal acute brain disease in Muzaffarpur district in Bihar (and in neighboring
districts), convincingly proved as "hypoglycemic encephalopathy" is caused by three factors; (1)
undernourished children, (2) prolonged fasting, and (3) easy access to and consumption of litchi.

“I was invited to help by Bihar government officials. Investigations about the cause of the "acute
encephalitis syndrome" from 1995 till 2012 had not come up with any conclusion. I visited in 2013
disease season and my findings were (1). Disease was not at all encephalitis but encephalopathy. (2) All
cases had early an onset of disease (missed by all earlier investigators) -- and that is typical of
"hypoglycemic" association, later proved conclusively. (3) Seasonality strictly coinciding with litchi
harvesting was not merely co-incidental but epidemiologically associated as they overlapped every year.
(4) Ackee is known to induce hypoglycemic encephalopathy; we found within a few days that ackee and
litchi belong to one plant family. (5) Soon thereafter, my colleague Mukul Das found out that German
researchers had documented presence of a hypoglycin, analogue of its counterpart in ackee, in litchi
seeds. (6) All paediatricians had noticed that ill children were always undernourished. So we made a
provisional diagnosis of litchi-triggered hypoglycemic encephalopathy in undernourished children – by
history, we had learned that many children went to bed skipping evening meal. That made us recommend
a cooked meal for all children. Many children belonged to litchi harvesting labour families. Next, we
prospectively investigated and showed clinically disease was hypoglycemic encephalopathy. The next
year, we showed hypoglycin G in litchi fruit pulp.

One cooked meal before bed and parental restriction of litchi was recommended. After onset, early
infusion of 10% dextrose reverses the encephalopathy by turning off gluconeogenesis; 5% dextrose is
enough to correct hypoglycemia but 10% results in insulin secretion (theory) and in turn turns off fatty
acid oxidation for gluconeogenesis.

Dr. Jacob also opined that the government should abandon the term AES (acute encephalitis syndrome)
and make clinical diagnosis with diagnostic criteria mandatory -- distinguish between encephalitis,
encephalopathy, meningitis, cerebral malaria, scrub typhus, etc. and not club all these into one basket of
AES. Litchi itself is safe for healthy people including well-nourished children. The unique situation in
Muzaffarpur should not to be the reason to malign litchi. He also mentioned that when the physicians in
Muzaffarpur tried the 10% glucose therapy, they were surprised by the quick recovery of the children.
They called it as a miracle.

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 Litchi, the Unlucky Fruit: What does the Evidence Say?

APPENDIX C

Beef Scare from the Mad Cow Disease in the United Kingdom

Beef or cattle meat forms a substantial part of the diet for a major percentage of the people around the
world. In 2016 alone, 129.5 billion pounds of cattle meat was consumed by the world (Cook, 2019),
indicating its popularity. In 1986, a disease that affects the central nervous system of the cows – called the
Bovine Spongiform Encephalopathy (BSE), or commonly called as the Mad Cow Disease – was
discovered in the United Kingdom. BSE-infected cows generally become aggressive and lose their
coordinating abilities, and in most cases leading to death. This disease gets transmitted to the cattle via
cattle feed that has BSE-infected protein sources. Human beings can acquire the disease Variant
Creutzfeldt-Jakob disease (or vCJD) if meat contaminated with BSE is consumed. In human beings, the
symptoms include psychiatric disorder and behavioral changes, which eventually lead to death. The
British government stood by the no-risk theory for a decade since the discovery of disease.

BSE was first discovered in the United Kingdom in 1986 and became an epidemic by 1993 as more than
1000 new cases of infected cattle were reported every week. The chance of acquiring vCJD on consuming
BSE infected meat was established a decade later after the discovery of BSE. In 1996, 10 people were
discovered with vCJD in the United Kingdom and it was announced that there could be a connection
between BSE and vCJD. Immediately, the entire beef market in the United Kingdom collapsed – beef
consumption dropped to 20% and countries around the world stopped importing beef from the United
Kingdom. European Union also had to bear a loss of 2.8 billion US dollars in providing subsidy to the
beef industry (Powell, 2003). Similar instances were reported in Canada and United States in 2003.

At the peak of the epidemic in 1992, almost 4.4 million cows were slaughtered as a precautionary
measure in the United Kingdom (BBC News, 2018). Since the linkage between BSE causing vCJD was
established, 231 people from 11 countries have been reported to have cases of vCJD (CNN Health, 2019)
and among them, 178 deaths have been associated with vCJD. The situation has now improved with very
fewer reports on BSE/mad cow disease, which is a relief for the beef industry.

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