Young mother Samina had to take another day off from work, once again because her daughter was suffering from diarrhoea. This was the third bout of the disease in as many months and the child was not gaining weight either. When they reached the hospital, a doctor told her that she had been lucky as the child survived each bout with simple medication. But a few days later, the diarrhoea returned. Rinse, repeat.

Samina is not alone in her predicament. Diarrhoea is not only the second leading cause of death in children under five years old in Pakistan, but is also one of the leading causes of malnutrition amongst children under five.

Although diarrhoea is both preventable and treatable, there is a greater focus on medicating rather than on how to prevent it better. In the former case, the strategy is reactive: medicines only work once a child falls ill. But the latter dynamic is more holistic: disease is controlled by ensuring that the environment around a child is not conducive to the outbreak of disease.

Towards this end, it is worth revisiting the seven-point plan drawn up by the WHO and Unicef to combat diarrhoea. The treatment package, as outlined in a 2004 joint statement from the Unicef and WHO, focuses on two main elements: fluid replacement to prevent dehydration and zinc treatment. As a whole, this is a comprehensive package for the prevention and control of diarrhoea, and contains both therapeutic and preventive interventions.

The incidence of diarrhoeal diseases can only be lowered by supplementing medical intervention with preventive measures

The preventive package highlights five main elements that require an integrated approach for implementation. The package includes: rotavirus and measles vaccinations; initiation of early and exclusive breastfeeding and vitamin A supplementation; promotion of washing hands with soap; improved water supply, quantity and quality, including treatment and safe storage of household water; and community-wide sanitation promotion.

The preventive components are of great help when it comes in the shape of an integrated package. These interventions have been tested internationally independently for the treatment of diarrhoea and it is believed that when implemented as a whole the seven-point package can greatly decrease the incidence of diarrhoea.

Each year, worldwide an estimated 2.5 billion cases of diarrhoea occur among children under five years of age. More than half of these cases are in Africa and South Asia, where bouts of diarrhoea are more likely to result in death or other severe outcomes. The incidence of diarrhoeal diseases varies greatly with the seasons and the child’s age. The younger the child the more vulnerable he is: the incidence being highest in the first two years of life and declines as a child grows older.

Includes neonatal deaths Source: Liu et al. Lancet 2012

Around 100-150 children in Pakistan lose their lives every day due to diarrhoea or related illness; Pakistan Demographic Health Survey (2012-13) puts the annual figures at 53,300. A large number of these deaths can be prevented by improved hygiene, safe drinking water and adequate sanitation. Some 60-75 million people in the country are affected by diarrhoea-related illnesses annually putting lot of burden on secondary level healthcare facilities.

The severity can be judged from the fact that diarrhoea kills more children than malaria, measles, and Aids combined. Chart No 2 clearly illustrates the proportional distribution of cause-specific deaths among children under five years of age.

According to the Pakistan Demographic Health Survey (PDHS) 2006-7, 22 per cent of children suffered from diarrhoea at some point during the last six weeks before the survey, while the PDHS of 2012-13 revealed that 23pc of mothers reported that their children suffered from diarrhoea in the past two weeks. These figures indicate that no change could be witnessed regarding a decrease in diarrhoeal diseases in the last decade.

Perhaps it is high time for provincial health departments to set their act straight. This would require not only incorporating medical interventions but also to get on board local governments and communities to adopt the seven-point plan.

Published in Dawn, Sunday Magazine July 26th, 2015

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