Anshula Tiwari - Public Health Team
Picture by Business Standard
In 1984, Sheila Zurbriggf wrote a story about her visit to Pattam village in Tamil Nadu. The story is about a mother, Rakku, who tries her best to save the life of her infant child suffering with a severe diarrheal episode. Zurbrigg writes about the terror that engulfs Rakku as she realizes her child has an ailment which has taken the lives of many children in her village, and about her tireless efforts to save his life against all odds. The odds here is essentially poverty, which, in India, comes with a simultaneous burden of lack of access to healthcare, inhuman treatment by the authorities and the obligation to resort to undue means in order to receive services which should have otherwise been unconditionally available. Rakku’s story heartbreakingly depicts the somber reality of how sometimes doing everything within your means is not enough, and of how, if you’re powerless, the entire system can work against you.
Rakku’s child had a seemingly uncomplicated ailment – diarrhea -- but it nonetheless took his life. There is obviously something wrong here. How can a simple condition with a simple treatment prove so dangerous? This essay will attempt to answer this question, specifically, why diarrhea is responsible for such a large burden of child mortality in India.
Diarrhea is the second leading cause of child mortality in the world, as is responsible for the death of almost 1.3 million children every year. Around 80% of these deaths occur in only two regions, namely South Asia and Africa. With 400,000 deaths occurring in India alone, it takes the lead in child mortality due to diarrhea within South Asia.
Diarrhea is a water and excreta related disease, and its principal method of spread is through the fecal-oral cycle. The only way to break this cycle is via proper hygiene such as safe disposal of stools, washing hands, improved waste management and better water supply.
Diarrhea remains a grave health concern in India, especially in the rural areas. There are several reasons for this. Many-a-times, diarrhea can be the manifestation of a variety of other diseases, which is not taken into account. As these underlying diseases are ignored, it results in the worsening of health over time, eventually making it, in many situations, incurable. In a research done by the World Health Organisation (WHO), 34% of diarrheal deaths were caused by rotavirus. Although India has launched the rotavirus vaccine under the Universal Immunization Program in 2016, implementation remains slow. Pneumonia is another disease which either accompanies diarrheal episodes, or causes it. Other diseases include HIV, COVID-19, E Coli and measles. There is a lack of knowledge amongst rural healthcare professionals on these underlying causes, which is exasperated by the lack of infrastructure such as labs necessary to diagnose these diseases.
Zinc capsules, in addition to Oral Rehydration Solution (ORS) is a standard treatment for diarrhea. However, this seemingly simple treatment has faced several roadblocks in its implementation in the Indian context. One of the main reasons zinc and antimotility drugs are not more prevalently used to cure diarrhea could be because there is a lack of contact between pharmaceutical companies and local medical facilities/ shops. This leads to a dearth of availability in rural areas. This in turn could be because there is a lack of incentive or government pressure on these pharmaceutical companies to better democratize the availability of their drugs, which means there is a failure of public-private partnership. Furthermore, there is a lack of expertise on how to use ORS; for instance, on how to dose it. There are also certain behavioral impediments to ORS usage. According to a research done by Zwisler et al, there is an apprehension to give a child ORS because it tastes bad, it does not relieve symptoms and because it does not look like real medicine. Lastly, there is an inadequate availability of resources for children who are too sick to intake ORS or any other medicine orally, and have to thus take it via intravenous methods.
Another reason for high mortality due to diarrhea is the irrational use of antibiotics or the administration of too many medicines at the same time. According to Anita Kotwani, since most diarrheic episodes are caused by viruses and not bacteria, antibiotics are not recommended. This erroneous information about medicines is partly because there is insufficient drug monitoring on behalf of the government, which in turn could be because of lack of finances, lack of HR and lack of a decentralized network of drug monitoring which is accessible to all hospitals, clinics and shops. It is also because of the lack of expertise or awareness of health care providers, especially in rural India. A massive problem which plagues rural India and can be considered to be a reason for mortality for all major diseases is the lack of private hospitals in these areas. Going with the broad assumption that private hospitals are capable of providing better and more specialized services, their unavailability in a large part of the country is a serious concern. Frustratingly, even if these hospitals are available, they are more often than not beyond the financial capabilities of most. In a study done by analyzing data of the National Sample Survey (NSSO) it was found that around 40 million people above poverty line were pushed to below poverty line in rural areas due to the extremely high out-of-pocket expenses of healthcare. India’s healthcare system is becoming increasingly unequal, and its positive correlation with mortality and poverty is overtly discernable.
These were the infrastructural and systemic causes for the high diarrheal mortality of children. However, there are several socio-cultural reasons which contribute to this as well. As mentioned earlier, diarrhea is a water and excreta related disease which can be prevented by efficient hygiene practices. However, this is lacking in several rural regions of the country. The lack of toilet facilities, prevalence of open defecation and a general assumption that the feces of children is harmless and can thus be disposed of without adequate safety measures are some of the socio-cultural reasons. A study done by Bawankule (2017) stated that the stools of 79% of children in the country were disposed off unsafely. Furthermore, the inability to access water which is treated and safe for drinking is a huge contributor to diarrhea in the country.
While child mortality due to diarrhea is in general very high, it is even higher for girls. This is because malnutrition, which can exasperate diarrheal conditions, is more prevalent amongst girls. Additionally, the son's preference and overall apprehension towards a girl child in India (and around the world) has meant that many families decide to leave the child untreated or to give her substandard treatment. This bias is visible in many ways, including the mortality statistics of diarrhea.
In conclusion, this paper has attempted to analyze the variety of reasons as to why so many children are dying due to diarrhea in India. In general, there is a massive lack of know-do gap amongst healthcare providers. Many people prefer to take the help of informal healthcare providers, because they are cheaper, more easily available and have a personal bond with that particular village or community. However, their remedies can be harmful, and the regulation of these informal providers is severely lacking in the country. In addition to this, several socio-cultural reasons such as lack of hygiene, toilet facilities and clean water, have made the situation infinitely worse and these problems cannot be solved without adequate governmental intervention.
I will end this paper by referring again to Rakku’s story. For anyone who is interested, it intricately lays down all the aforementioned points and the plight of the poor and uneducated in accessing state healthcare services. What stays with the reader for days after is not only the helplessness of a mother trying to save her child from a disease which should not have been fatal, but also the quiet acceptance of this fate. There are millions in the country who likewise accept the premature death of their children because they know of no other reality, and this is a huge failure which needs to be urgently remedied.
Anshula is currently pursuing her masters in ‘Public Policy’ from O.P. Jindal. She has, prior to this, completed her bachelors in History from Delhi University, and her masters in ‘Global History and International Relations’ from Erasmus University, Rotterdam.