Acute Respiratory Infection (ARI) kills too many Himalayan children. It is a painful way to die: infection, either bacterial or viral, fills the lungs with puss and the child literally suffocates to death. Unfortunately, ARI is the poor person’s disease, so it has not been studied till very recently. Caused by poor housing, indoor smoke, lack of protection from the cold, poor hygiene and malnutrition, most deaths occur due to delayed diagnosis and treatment.
Severe cases of ARI, manifested as pneumonia kill as many as 720,000 children in India. In Nepal, about 25 percent of the approximately 135,000 under five children who die every year succumb to ARI. How have these cruel statistics persisted? According to Dr. Mrigendra Raj Pandey, even as medical care became more organised, health planners left ARI alone because of its complexity. They concentrated instead on communicable diseases, immunisations and diarrhea. “It is difficult to imagine a primary health care programme that does not include an organised approach to counteract the leading causes of ARI related deaths,” he said a few years ago.
GOALS FOR 2000
In Nepal, the official myopia regarding ARI has now been corrected, due in part to the pioneering work by the Mrigendra Medical Trust, which established that domestic smoke pollution is an important cause of chronic bronchitis and ARI. A National ARI Task Force which began work in 1987 in one of Nepal’s districts has expanded its ‘activity to 14 districts. Combatting ARI has now been incorporated into the nation’s Basic Needs Programme and the official goal is to reduce infant mortality due to ARI by 50 percent by the turn of the century. Meanwhile, ARI control was also been given high priority at scientific meetings held under the aegis of the South Asian Association for Regional Cooperation (SAARC).
The pilot project was conducted in the Tamang villages of Chhaimale and Talku Dundechaur, whose inhabitants are predominantly illiterate farmers subsisting on hill terraces. Tobacco smoking is common among both men and women, and indoor smoke pollution is severe. Akshya Gautam, the project’s field coordinator, said the Tamangs were found living in extremely unhygienic conditions. They ate a lot of stale food and even in households where cows and buffaloes were kept, the norm was to sell butter and ghee in the market rather than to let the children drink milk.
Before the project began in 1985, 162 out of every thousand infants failed to survive beyond their first year in these two villages. Of these, 43 died from AR1. The Trust was able to reduce the mortality rate to 98 per thousand, primarily by reducing ARI deaths. The reduction in deaths occurred primarily because of health education, encouragement of breast feeding, immunisation and anti-microbial treatment.
According to Dr. Pandey, the dramatic improvement was achieved mainly because all potentially life threatening infections were detected before they had become too severe and were treated with antibiotics known for their effectiveness. Almost as important was the education of the mothers which made them seek medical attention more readily, he said.
Due to its painstaking work, Dr. Pandey’s team has also slowly gained the trust of the villagers, among whom superstition is rife. They blamed the visible symptoms of ARI, chest retraction and fast and panicky breathing, on the evil eye. Says Ram Prasad Neupane, a research officer, “We tell them to go ahead with their rituals but to please let us administer modern medicine at the same time.”
And it is working. Fewer and fewer children are dying in Chhaimale and Talku Dundechaur. With the coaxing of a philanthropic organisation with medical expertise and an understanding of local conditions, the villagers are learning to defend against their evil spirits, the various infection of ARI.
By the year 2000, the whole country should be rid of these spirits, so that no more young lives are lost to the ARI demon. For that to happen, however, the Trust’s success in the two Tamang hamlets will have to be repeated everywhere. As Dr. Pandey himself cautioned in a report to UNICEF, “The intensity by which we were able to work in a pilot research project can not be replicated at the national level.
The Mrigendra Trust
A successful Kathmandu cardiologist who had made a name for himself treating the rich and powerful was suddenly jolted into an acute awareness of the entrenched poverty and endemic disease afflicting the people of rural Nepal. While others might have let that moment of revelation pass with nothing but a twinge of conscience, Dr. Mrigendra Raj Pandey put his money where his mind was.
In 1975, Dr. Pandey set up the Mrigendra Medical Trust, with the goal of providing medical treatment and health education, and conducting research, all for the benefit of the poor. What began as a personal crusade has, over the past decade, gained an institutional permanence, and an ability to set an agenda in a country where voluntary groups generally wither away as soon as they are born.
At first, the Trust limited its work to providing medical services to the people in the Sundarijal area North East of Kathmandu, and it also opened a clinic for diabetic patients in the city. But the Trust soon realised that the passive distribution of drugs and medical care could even be counter productive if not supplemented by a broader programme of social awareness.
Accordingly, it organised a programme to supplement village income by providing charkha looms, encouraged village discussion groups to debate what was being done for them, provided scholarships for school children, and even organised spiritual activities to enhance the quality of life. This January, for example, the Trust coordinated a mass (bratabandha) sacred thread ceremony to avoid the economic burden of ostentatious ceremonies. The villagers, too, have met the challenge set by the Trust. For example, the Sundarijal clinic, is now run by the community.
The Trust has also became increasingly involved in medical research. It has done pioneering work on the study of Acute Respiratory Infection (ARI). While investigating the causes of the disease, the Trust found that it could not study the problem of ARI in isolation from other killer diseases, such as diarrhea and other infections. Neither could an “intervention” remain isolated from the traditions, beliefs and expectations of the village populace. In the pilot area where it is studying ARI, the Trust hopes to bring down the infant mortality rate from 162 per one thousand presently, to 45 by the year 1990. Indications are that it will achieve that target.