Prof Grace Irimu shows IPS a drip feed bag and a copy of Kenya’s ‘Basic Paediatric Protocols’ as she explains the importance of intravenous treatment in saving the lives of young children affected by acute watery diarrhoea. Credit: Miriam Gathigah/IPS

By Miriam Gathigah
NAIROBI, May 23 2015 (IPS)

Acute watery diarrhoea is a major killer of young children but misunderstanding over the benefits of fluid treatment is preventing many Kenyan parents from resorting to this life-saving technique and threatening to reverse the strides that the country has made in child health.

The 2014 Kenya Demographic and Health Survey, released in April this year, reports that the country’s under-five mortality rate fell to 52 deaths per 1,000 live births in 2014, down from the 74 deaths in 2008-09, but still far from the 32 per 1,000 live births targeted under the Millennium Development Goals (MDGs).“Parents must … understand that rapid fluid treatment is life-saving for children diagnosed with shock or poor blood circulation due to diarrhoea” – Prof Grace Irimu, Associate Professor of Paediatrics, University of Nairobi

The primary treatment for acute watery diarrhoea is rehydration, administered intravenously in the most severe cases of very young children suffering from shock after losing excessively high quantities of body fluids. A fluid bolus – or rapid liquid dose – delivered directly through an intravenous drip allows a much faster delivery than oral rehydration.

However, notes nurse Esther Mayaka at the Jamii Clinic in Mathare, Nairobi, “parents of children brought to hospital with acute watery diarrhoea are refusing to have them put on [drip] fluid treatment and this is a major concern because diarrhoea is a leading killer among children and giving fluids is still the main solution.”

She told IPS that the ongoing rains and floods in many parts of the country “have created a comeback for diseases like cholera whose most telling sign is watery diarrhoea which needs to be managed with fluids.”

In February this year, Kenya’s Director of Medical Services, Dr Nicholas Muraguri, issued a cholera outbreak alert following an increase in cases of acute watery diarrhoea in several counties, including Homa Bay, Migori and Nairobi.

According to Prof Grace Irimu, Associate Professor of Paediatrics at the University of Nairobi, the reluctance to resort to drip fluid treatment has arisen due to misunderstanding generated by a Fluid Expansion As Supportive Therapy (FEAST) study in 2011 to establish whether the bolus technique was the best practice to use among children diagnosed with shock.

The FEAST study, which was conducted among children in Kenya, Tanzania and Uganda, found that fluid boluses increased 48-hour mortality in critically-ill children with poor blood circulation or shock in these resource-limited settings in Africa, but Irimu told IPS that the study excluded diarrhoea and only studied illnesses associated with fever, such malaria and sepsis.

“Parents must therefore understand that rapid fluid treatment is life-saving for children diagnosed with shock or poor blood circulation due to diarrhoea,” she said.

The Kenya Paediatric Association is also trying to set the record straight and, in a statement shared with IPS, the association reiterated that “diarrhoea complicated by severe dehydration is one of the biggest killers of children globally.”

According to the paediatrics association, the FEAST study excluded children with diarrhoea and dehydration because “the value of giving fluids in this group is well known. Giving appropriate fluid therapy is essential.”

Prof Irimu told IPS that the FEAST study had led to a revision of the ‘Basic Paediatric Protocols’, Kenya’s national guidelines for paediatric care, and clauses that address the treatment of diarrhoea were also revised.

Previously, a child diagnosed with shock as a result of diarrhoea would be given fluids in three cycles, every 15 minutes depending on the response. Now, the child receives the fluids in two cycles and if there is no response, health providers are advised to proceed to slower fluid administration where the child is given the amount that the body needs, depending on the level of dehydration.

Meanwhile, the country continues to make strides in dealing with HIV/AIDS – another critical health issue covered by the MDGs – among children. Studies show that the number of children with HIV aged between 18 months and 14 years fell from 184,000 in 2007 to 104,000 in 2012, according to the most recent Kenya Aids Indicator Survey.

However, Prof Joseph Karanja, a reproductive health and HIV/AIDs expert in Nairobi, says that the country can still do better because “through available antiretroviral drugs as a preventive measure among HIV positive mothers, HIV transmission to the infant can be reduced to as low as one percent.”

Dr Pauline Samia, a paediatric neurologist and a board member of the Kenya Paediatric Association, says that there is also a commitment to address conditions that challenge the management of HIV among children such as epilepsy.

“Though research in this area is limited, an estimated 6.7 percent of children with HIV also have epilepsy, with at least 50 percent of children with HIV having central nervous system problems such as delayed development, behavioural challenges and convulsions,” she observes.

Regarding progress in other MDGs, some progress has been made in reducing the prevalence of underweight children less than five years of age, one of the goals set for eradicating extreme hunger and poverty.

The 2014 Kenya Demographic and Health Survey reports that not only has childhood malnutrition declined significantly, from 35 percent in 2008 to the current 26 percent, but the prevalence of underweight children also decreased from 16 percent in 2008 to 11 percent in 2014.

On the front of improving maternal health, the survey says that while maternal mortality remains high at 488 deaths in every 100,000 live births, in the past five years more than three in five births (61 percent) took place in healthcare facilities, a marked improvement compared with the 43 percent in 2008.

Edited by Phil Harris   

CLEAN-India is an environmental assessment, awareness, action, and advocacy programme that promotes behavioural change among young city dwellers in India. As part of the programme, a group of female students learns about the importance of clean water. Credit: Development Alternatives

By Prerna Sodhi
NEW DELHI, May 16 2015 (IPS)

“Swachh Bharat”, or Clean India, is a slogan that most Indians today associate with the country’s Prime Minister Narendra Modi and his first nation-wide campaign launched soon after taking office in 2014.

The call has definitely awakened popular consciousness on cleanliness but whether citizens follow it or not is another matter. In fact, it is commonplace to find people calling out “Swachh Bharat” as they toss garbage onto the street.

However, while the campaign may not have brought about the change it was aimed to usher in, a dialogue has started and it is a watershed moment for all those working in this area to capitalise on its momentum.The call for “Swachh Bharat”, or Clean India, has definitely awakened popular consciousness on cleanliness but whether citizens follow it or not is another matter

The idea of cleaning India up is not new, and neither is the term “Swachh Bharat” which has been used by many in the past and has now been “patented” by Modi. For decades, there has been concern with instilling an awareness of the need for cleanliness among citizens, many of whom even defecate in the open.

The current initiative by the government may address the issue of cleanliness at citizens’ level, but activists in the field of sustainable development argue that it should also cover issues related to water, energy and sewage disposal cleanliness.

Access to clean water is one of the main problems that the country faces. According to a report by UNICEF (the U.N. Children’s Agency) and the Food and Agriculture Organisation (FAO), every year around 37.7 million Indians are affected by waterborne diseases, 1.5 million children die of diarrhoea alone and 73 million working days are lost due to waterborne diseases.

The problem does not appear to lie in the lack of availability of water treatment methods, but rather in the unwillingness of people to adopt these methods.

“From the field, we observed that the lack of adoption of water purification techniques is not due to low awareness levels and it was not even illiteracy, as is often assumed,” said Kavneet Kaur, field manager for Development Alternatives (DA), a social enterprise set up in 1982 to tackle the serious impact of climate change on society and the environment.

“There was an evident lack of effort and prioritisation of safety among people to undertake one or more options consistently that made drinking water safe,” she added.

Most slum dwellers, for example, “opted for methods that did not cost their pocket a penny. Those who did have access to cheaper methods of treatment, like chlorination and solar water disinfection (SODIS), avoided adopting these methods because they were time consuming.”

For the last 30 years, DA, which works primarily in Bundelkhand in central India, has been addressing the behaviour change necessary for people to adopt water treatment methods.

According to Dr K. Vijaya Lakshmi, DA Vice President, out of the three interrelated components of water, sanitation and hygiene, “hygiene behaviour has been shown to have the biggest impact on community health.”

However, she notes, “despite its merit as the most cost effective public health intervention, ironically there was no global target to improve hygiene during the Millennium Development Goal (MDG) era. It has become evident that the MDG framework has fallen short of addressing quality, sustainability and equity issues.”

To date, DA has reached out to 50,000 households and 26 schools through intensive advocacy campaigns in urban villages, offering training on how to adopt safe water treatment methods such as SODIS, boiling, chlorination and sieving, despite meeting strong resistance from the local population.

For example, storing water in a PET (polyethylene terephthalate) bottle exposed to sunlight can kill up to 99 percent of the bacteria in the water, an “innovation” that uses nothing but natural ultraviolet (UV) light to provide safe drinking water for consumption. Water can also be purified by sieving boiled water.

Apart from advocating the adoption of these simple water purification methods, DA has also come up with innovations like the Jal-TARA Water Filter, which removes arsenic, pathogenic bacteria and excess iron from contaminated water, TARA Aqua+ (a sodium hypochlorite solution for purifying water), and TARA Aquacheck Vial, a device that tests for the presence of pathogenic bacteria.

Nevertheless, these innovations are not destined to go very far unless there is a major change in the mindset of the Indian people, and this extends to the “Swachh Bharat” campaign, not just in terms of clean water but also of a cleaner environment.

This idea has also been the driving force behind a youth-led social media campaign known as CLEAN-India ‘The City I Want’, launched by SA and now covering ten Indian cities – Mirzapur, Mohali, Vadodara, Alwar, Ambala, Bharatpur, Indore, Nashik, Mussoorie and Rishikesh.

CLEAN-India (where CLEAN stands for Community Led Environment Action Network) is an environmental assessment, awareness, action and advocacy programme that promotes behavioural change among young city dwellers. It has so far mobilised 28 NGOs, 300 schools, 800 teachers and over one million students.

The campaign is flanked by a number of other citizens’ groups such as resident welfare associations, parent forums, local business associations and clubs, which are actively participating in activities for environmental improvement.

“Going forward, it is crucial that civil society organisation practitioners interface with academic institutions in evidence gathering and inform policy-makers and investors in order to create enabling conditions where scalable innovation can flourish,” says Lakshmi.

Edited by Phil Harris   

Excerpt:

Syrian mother and child near Ma'arat Al-Numan, rebel-held Syria, in autumn 2013. Credit: Shelly Kittleson/IPS

By Shelly Kittleson
BEIRUT, Jul 19 2014 (IPS)

Gaunt, haggard Syrian children begging and selling gum have become a fixture in streets of the Lebanese capital; having fled the ongoing conflict, they continue to be stalked by its effects.

Most who make it across the Syria-Lebanon border live in informal settlements in extremely poor hygienic conditions, which for many means diarrhoeal diseases, malnutrition, and – for the most vulnerable – sometimes death.

By the end of January, almost 40,000 Syrian children had been born as refugees, while the total number of minors who had fled abroad quadrupled to over 1.2 million between March 2013 and March 2014.Most who make it across the Syria-Lebanon border live in informal settlements in extremely poor hygienic conditions, which for many means diarrhoeal diseases, malnutrition, and – for the most vulnerable – sometimes death.

Lack of proper healthcare, food and clean water has resulted in countless loss of life during the Syrian conflict, now well into its fourth year. These deaths are left out of the daily tallies of ‘war casualties’, even as stunted bodies and emaciated faces peer out of photos from areas under siege.

The case of the Yarmouk Palestinian camp on the outskirts of Damascus momentarily grabbed the international community’s attention earlier this year, when Amnesty International released a report detailing the deaths of nearly 200 people under a government siege. Many other areas have experienced and continue to suffer the same fate, out of the public spotlight.

A Palestinian-Syrian originally from Yarmouk who has escaped abroad told IPS that some of her family are still in Hajar Al-Aswad, an area near Damascus with a population of roughly 600,000 prior to the conflict. She said that those trapped in the area were suffering ‘’as badly if not worse than in Yarmouk’’ and had been subjected to equally brutal starvation tactics. The area has, however, failed to garner similar attention.

The city of Homs, one of the first to rise up against President Bashar Al-Assad’s regime, was also kept under regime siege for three years until May of this year, when Syrian troops and foreign Hezbollah fighters took control.

With the Syria conflict well into its fourth year, the U.N. Security Council decided for the first time on July 14 to authorize cross-border aid without the Assad government’s approval via four border crossings in neighbouring states. The resolution established a monitoring mechanism for a 180-day period for loading aid convoys in Turkey, Iraq and Jordan.

The first supplies will include water sanitation tablets and hygiene kits, essential to preventing the water-borne diseases responsible for diarrhoea – which, in turn, produces severe states of malnutrition.

Miram Azar, from UNICEF’s Beirut office, told IPS that  ‘’prior to the Syria crisis, malnutrition was not common in Lebanon or Syria, so UNICEF and other actors have had to educate public health providers on the detection, monitoring and treatment’’ even before beginning to deal with the issue itself.

However, it was already on the rise: ‘’malnutrition was a challenge to Syria even before the conflict’’, said a UNICEF report released this year. ‘’The number of stunted children – those too short for their age and whose brain may not properly develop – rose from 23 to 29 per cent between 2009 and 2011.’’

Malnutrition experienced in the first 1,000 days of a child’s life (from pregnancy to two years old) results in lifelong consequences, including greater susceptibility to illness, obesity, reduced cognitive abilities and lower development potential of the nation they live in.

Azar noted that ‘’malnutrition is a concern due to the deteriorating food security faced by refugees before they left Syria’’ as well as ‘’the increase in food prices during winter.’’

The Syrian economy has been crippled by the conflict and crop production has fallen drastically. Violence has destroyed farms, razed fields and displaced farmers.

The price of basic foodstuffs has become prohibitive in many areas. On a visit to rebel-held areas in the northern Idlib province autumn of 2013, residents told IPS that the cost of staples such as rice and bread had risen by more than ten times their cost prior to the conflict, and in other areas inflation was worse.

Jihad Yazigi , an expert on the Syrian economy, argued in a European Council on Foreign Affairs (ECFR) policy brief published earlier this year that the war economy, which ‘’both feeds directly off the violence and incentivises continued fighting’’, was becoming ever more entrenched.

Meanwhile, political prisoners who have been released as a result of amnesties tell stories of severe water and food deprivation within jails. Many were detained on the basis of peaceful activities, including exercising their right to freedom of expression and providing humanitarian aid, on the basis of a counterterrorism law adopted by the government in July 2012.

There are no accurate figures available for Syria’s prison population. However, the monitoring group, Violations Documentation Centre, reports that 40,853 people detained since the start of the uprising in March 2011 remain in jail.

Maher Esber, a former political prisoner who was in one of Syria’s most notorious jails between 2006 and 2011 and is now an activist living in the Lebanese capital, told IPS that it was normal for taps to be turned on for only 10 minutes per day for drinking and hygiene purposes in the detention facilities.

Much of the country’s water supply has also been damaged or destroyed over the past years, with knock-on effects on infectious diseases and malnutrition. A major pumping station in Aleppo was damaged on May 10, leaving roughly half what was previously Syria’s most populated city without running water. Relentless regime barrel bombing has made it impossible to fix the mains, and experts have warned of a potential humanitarian catastrophe for those still inside the city.

The U.N. decision earlier this month was made subsequent to refusal by the Syrian regime to comply with a February resolution demanding rapid, safe, and unhindered access, and the Syrian regime had warned that it considered non-authorised aid deliveries into rebel-held areas as an attack.