08/08/2016 8:58 PM IST | Updated 12/08/2016 8:56 AM IST

Death By Ignorance: Why India Needs To Talk About Shit

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Anywhere between one to three lakh Indian children are going to die because of ignorance by the end of the year. Think about that. By the time your day gets over, the lives of about 328 boys and girls will have ended. None of them will see their fifth birthday and none of them really had to die. The immediate cause of their death will be an innocuous ailment, the running stomach. We are all familiar with it, and most of us pretend to have it every so often when we want to skip work. Diarrhoea is also an easily curable disease. In most cases, hygienic conditions and healthy food will get rid of it for you. So how can it kill so many children? It cannot. Not without help from the real culprit -- ignorance.

The problem

Acute non-bloody diarrhoea (which excludes dysentery) can be easily cured with a 10-14 day course of zinc and oral rehydration salts (ORS). Zinc in its sulphate or acetate forms is a potent and temporarily prophylactic cure for the disease. Taken alongside, ORS ensures that severe dehydration does not set in. The role of ORS is crucial as loss of water is most often the direct cause of death in such cases. Neither of these medicines is very expensive or difficult to obtain. They are also a part of the essential medicines kit carried by the vast network of public frontline health workers in rural areas, and are therefore technically available for free to those who need them. Despite all this, the statistical oracle will find its grim prophecy fulfilled.

How can diarrhoea kill so many children? It cannot. Not without help from the real culprit -- ignorance.

The reason is easily understood even if not accepted. A negligible percentage of the households covered in any study on the subject are found to be aware of the medicinal uses of zinc. ORS manages a more respectable recall, largely because of government mass media campaigns over several decades. But the flipside is that people mistakenly consider ORS itself to be a cure for diarrhoea. It isn't. It only tackles dehydration. This lack of information is not surprising given the overall paucity of education, and diarrhoea is just one of its many beneficiaries. While efforts to inform the masses continue, the progress is slow. A more urgent concern, however, is the ignorance of their rural healthcare providers.

The exacerbating "solution"

A poor villager will rarely share our good fortune of seeing a qualified general physician for the most frivolous of complaints. Government health services remain sparse over our densely populated landscape even with the infrastructure of impressive-sounding schemes such as the National Health Mission -- the difficulties in getting effective treatment in these facilities could be the subject of several articles on their own. The first point of contact for treatment in most villages is usually a bumbling, dangerous man, quaintly but not inaccurately called the rural medical practitioner (RMP). This official sounding designation merely hides the fact that this man is an unqualified person posing as a doctor. Some other rather derogatory appellations for him include quack and jholachaap. It needs to be clarified that RMPs are not practitioners of traditional medicine, but pretenders to allopathy.

The first point of contact for treatment in most villages is usually a bumbling, dangerous man called the rural medical practitioner (RMP).

Typically, they have no more than a high school education, and if the patient is lucky, some years spent apprenticed to senior RMPs, where they learn the basics of medicine, such as the use of Crocin. The best that such RMPs can offer is a placebo, or a temporary respite from symptoms. There are possibly bright minds among this group who over a period of learning and self-improvement manage to not grossly misdiagnose an ailment, but by and large, they depend on chance to maintain a low patient mortality rate.

In one visit to an RMP clinic, I witnessed my host peering for some time down the ear of a patient, who I later learned was complaining of pain in her leg. The others don't necessarily have better approaches to diagnosis. Their usual prescription is in the form of over-the-counter pills -- often just Paracetamol -- for any ailment. Injections are also given disproportionately, as they think that patients don't feel like they got their money's worth without it, and competition necessitates satisfied customers. While most of them do refer serious ailments to the nearest government hospitals or urban clinics, the time wasted in reaching this conclusion can be fatal, especially if the patient is an infant.

There are different schools of thought regarding what is to be done with these RMPs, ranging from "they should be trained and enabled", to "they shouldn't exist". But the reality remains that they do exist, and form a large part of the rural healthcare system. The reason is a gap between demand for healthcare and supply. Market failure helps them thrive. While I don't pretend to have solutions to this problem, it doesn't seem sufficient to declare them illegal and forget about it.

Deadly complicity

There is another form of ignorance which should also share the blame. This is the wilful ignorance of the urban privileged classes about how a majority of Indian people are living today. Based on informal and formal surveys, it is possible to conclude that neither diarrhoeal deaths nor public healthcare facilities are on the top of many people's priority lists. This is particularly unfortunate, given their unique position as the privileged class in a poor country, with easy access to information and means to share opinions that can allow them to influence government policy.

If enough people are heard taking an interest in problems that might never directly affect them, perhaps politicians will include issues such as public health and child mortality in their election promises. Who knows, they might even merit a primetime debate or two! The reasoning might be tenuous, but if by engaging with issues like public health, there is the slightest chance of lives being saved, it might be worth the effort.

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