Muzaffarpur, Bihar – On June 16, Krishna Kumar Verma, a farmer in Muzaffarpur’s Raghavpur village in the eastern Indian state of Bihar, was told by his sister Sita Devi that her son Ankit Kumar had a fever.

Verma had been following the outbreak of Acute Encephalitis Syndrome (AES) or “brain fever”, an illness locally known as Chamki Bukhar that affects the central nervous system and has killed more than 150 children this year, 131 in Muzaffarpur district alone.

Verma and Devi rushed Ankit to Sri Krishna Medical College and Hospital (SKMCH), roughly 17 kilometres away, where the four-year-old was administered some injections and medicines.

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With a slight improvement in the child’s condition, Verma said the doctors asked him to take him home.

“We refused and requested the doctor keep him in the hospital for the entire day since we feared it might be a case of brain fever,” he told Al Jazeera.

“However, the doctor insisted he is fine and that we could take him home.”

As soon as they left the hospital premises, the child began to vomit and convulse. Verma and Devi rushed him back to the ward, where he was earlier admitted.

“The doctor looked at his eyes and said he was dead,” said Verma. “We couldn’t believe his words and told him that just minutes ago, another doctor had told us he was fine and that we should take him home.”

A distraught Verma alleged they were not even provided with an ambulance by the hospital to take the dead child home and had to hire a private vehicle.

Muzaffarpur’s Sri Krishna Medical College and Hospital, where the children are being treated [Bilal Kuchay/Al Jazeera]

Shortage of doctors, medicines

With the number of children in Muzaffarpur dying due to AES escalating, the crisis has exposed the state’s dilapidated health sector. A similar outbreak in the district in 2014 killed 350 children, raising questions on why the authorities had not done more to combat the disease.

On Monday, India’s Supreme Court ordered an investigation into the deaths and issued a notice to both the Bihar and federal governments, accusing them of negligence.

Meanwhile, hospitals in Muzaffarpur and elsewhere in Bihar are feeling an acute shortage of doctors and nursing staff as well as the unavailability of medicines or beds for the patients.

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Last week, SKMCH authorities converted a ward meant for prisoners into a paediatric intensive care unit (ICU) to accommodate the rising number of children arriving at the state-run hospital.

“There were no beds available. Only a few doctors were attending to a huge rush of patients,” said Nirmala Devi, who on June 9 lost her son Rahul Kumar to brain fever in SKMCH.

“Multiple children were kept on the same bed in wards,” she told Al Jazeera. “If there were enough doctors to attend to patients, my son would have been alive.”

Last week, health workers in Bihar began a door-to-door campaign to detect cases of AES for early referral and treatment. The workers were provided with packets of Oral Rehydration Solution (ORS) for free distribution in the affected areas.

“After the death of over 150 children, the Bihar government has woken up and asking people that they should do this or that,” an angry Ali Hussain Mian from Raghavpur told Al Jazeera.

Hussain Mian lost his three-year-old daughter Asmeen Khatoon to the deadly brain fever on June 15.

“As a parent, I know the pain of losing a child. My appeal to [Bihar Chief Minister] Nitish Kumar’s government is to please focus on the state’s healthcare sector and improve the facilities in the hospitals so that no parent loses his child to such diseases in future,” he said.

At the SKMCH, nearly 110 deaths have been reported so far.

“So many children have died due to this brain fever,” said Kusheela Devi as she squatted outside the ICU of the hospital. “I am worried about my two grandchildren who are currently admitted here.”

Raghuveer Kumar, whose three-year-old nephew Sachin is also admitted, said he is “scared and in a lot of tension due to the daily deaths”.

Three patients with AES died while 15 new cases were registered in the hospital on Friday.

Triggered by malnutrition, heatwave

AES is mainly caused by dehydration and malnutrition. Early symptoms are similar to those of flu, with patients suffering from high temperatures or headache. Young children are particularly vulnerable to the illness, which can cause swelling of the brain, fever and vomiting.

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Since its outbreak earlier this month in Bihar, one of India’s poorest states, AES has wreaked havoc, affecting 20 out of the state’s 38 districts and killing 152 people at the last count.

About 6,000 deaths from encephalitis occurred in India between 2008 and 2014, with Bihar accounting for 1396 of those fatalities since 2008.

Muzaffarpur, with a population of nearly 5 million people, is the epicentre of the crisis. Of the 719 AES cases reported in Bihar this year, 602 were registered in the district alone.

The outbreak has been exacerbated by a record heatwave in the region, with temperatures in cities such as Patna and Gaya hovering above 45 degrees Celsius and killing over 180 people.

Daniram Kumar, 25, who sells lychees in Muzaffarpur, said he is running at a loss due to the AES outbreak [Bilal Kuchay/Al Jazeera]

Some studies have blamed the AES outbreak on lychees, a fruit grown in abundance in orchards around Muzaffarpur.

“Our investigation suggests an outbreak of acute encephalopathy in Muzaffarpur associated with both hypoglycin A and MCPG toxicity. To prevent illness and reduce mortality in the region, we recommended minimising lychee consumption, ensuring receipt of an evening meal and implementing rapid glucose correction for suspected illness,” scientists from the United States and India said in a joint study published in medical journal The Lancet in 2017.

However, Kaushal Kishor, additional secretary in Bihar’s health department, refused to link lychees with AES. “It’s all guesswork,” he said. “There is no conclusive evidence that lychees cause this disease.”

Experts said most of the children brought to the hospitals were malnourished.

“Malnutrition among children in Bihar is a serious issue. Half of the state’s children are stunted and one-fifth is wasted. This is a crisis that needs serious attention,” said Rabi Parhi, nutrition specialist with UNICEF in Bihar.

Dr Gopal Shankar Sahni, head of the department of paediatrics at SKMCH, attributed most of the deaths in his hospital to hypoglycaemia (low blood sugar) and electrolyte imbalance.

“Low blood sugar level and electrolyte imbalance due to heatwave and humidity are the main reasons for AES,” he said.

More deaths feared

On Friday, SKMCH superintendent Dr Sunil Kumar Sai, while talking to reporters, accepted that the hospital lacked the infrastructure to deal with the regular outbreak of brain fever in the area.

“If it rains tomorrow, the crisis will be over the next day,” he said.

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When a journalist asked him if the Bihar health system was now dependent on rains to contain the crisis, Dr Sai evaded the question and walked away.

On Saturday, it rained in Muzaffarpur, with officials saying no fresh AES case were reported on the day.

“One death was reported in Muzaffarpur in the last three days,” Shailesh Prasad Singh, a Bihar government’s medical officer, told Al Jazeera on Saturday. “We’re hoping that with the onset of the monsoon, the epidemic will further ease.”

However, Dr Sahni at the SKMCH said the hope that rains would reduce the brain fever death toll was misplaced.

“There are little chances that it will rain in Muzaffarpur in the next few days which would definitely lead to more AES cases coming to the hospital,” he said.