Diarrhoeal Diseases Current Status, Research Trends and Field Studies

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Title
Diarrhoeal Diseases
Current Status, Research Trends and Field Studies
extracted text
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SIR DORABJI TATA SYMPOSIUM SERIES

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Diarrhoeal Diseases
Current Status, Research Trends and Field Studies

J? series presenting the status reports on
tropicaldiseases in India

Editors
D. Raghunath
Principal Executive
Sir Dorabji Tata Centre for Research
in Tropical Diseases, Bangalore

R. Nayak
Professor and Chairman
Department ofMicrobiology and Cell Biology
Indian Institute ofScience
Bangalore
Sponsored by
Sir Dorabji Tata Trust
Society for Innovation and Development
Indian Institute of Science, Bangalore

On behalf of
Sir Dorabji Tala Centre for Tropical Diseases
in Conjunction with
Department ofMicrobiology and Cell Biology
Indian Institute of Science
Bangalore

§0
Volume 1: Status of Tuberculosis in India - 2000
Volume 2: Status of Malaria in India - 200.1
Vaccine Research in India
Volumes : Diarrhoeal Diseases: Current Status,
Research Trends and Field Studies - 2003

Tata McGraw-Hill Publishing Company Limited
NEW DELHI
McGraw-Hill Offices
New Delhi New York Si Louis San Francisco Auckland Bogota Caracas
Kuala Lumpu Lisbon London Madrid Mexico City Milan Montreal
San Juan Santiago Singapore Sydney Tokyo Toronto

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lhe Community Health Paradigm in DiarrhoealDisease Control
Dr. Ravi Narayan, MD, DTPH, DIH

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Community Health Adviser,
Society for (Community Health Awareness,
Research and Action, Bangalore
e-mail: sochara@vsnl.com

SOME REFLECTIONS
• Diarrhoeal diseases both acute or chronic continue to be a major
public health problem all over the world but especially so in the so
called developing countries, where their occurrence also becomes
reflective indicator of the state of health and sanitation of the
community and the well being of their children.
• In India, it is a major public health problem among the under-five age
group and it has been estimated that a third of the total paediatric
admissions are due to diarrhoeal diseases and up to 17 per cent of all
deaths in indoor paediatric patients are diarrhoea related.
• A study carried out in rural and urban areas of 11 states in the country
in 1991, found diarrhoea episodes of 1.5 per child per rear (urban)
and 4.7 per child per year (rural), perhaps an underestimate. SRS
estimates have shown that out of a child monality of 26.5 per 1000
children under-five, about 20 per cent deaths are due to diarrhoeal
diseases.
• The classical biomedical approach which has dominated public health
and medical research in the counrrv has focussed on the agent factors
including a large range of viruses, bacteria and other parasiti
infections. Iixtensive studies have been done on rotaviruses; Iz. coh
(both enterotoxigenic and enteropath-jemci.
Car^xhhhicter
ieijnni\ I 'ibrio cbolera\ Salmonella and Cr,jiosp 'rbia>a.
® This case centred specific pathogen oriented epidemiology seeks to
identity high risk affected or susceptible individuals and offers them
some treatment or protection and prevention. Thus leading to
the quest of drugs for treatment and prophylaxis or vaccines for
prophylaxis.

299

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Vibrio
cholera

E. coli
(ET)

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E. coli. (EPkZ

—Shigella

DIARRHOEAL
DISEASE

f

Rota
virus

,/Campylo­

Srypto\ sporidium
Salmonella\etc’

bacter

• There is however an urgent need to move from an ‘individual
oriented’ strategy to a population oriented strategy that seeks to
control the determinants of incidence
.c in the population as a whole.
• For diarrhoeal diseases taken togethicr as a whole, these population
based or social determinants are increasingly being understood. They
include:
=> Poverty
=> Malnutrition
=> Poor personal and community hygiene
=> Inadequate or unsafe water supply sources
Inadequate or absent sanitation facilities
=> Inappropriate feeding and weaning practices
FLY/Vermin
.breeding

Poverty

Malnutrition

Vivrio
Contami­ /XT
x, cholera
nated 11
food
' E. coli\ /jt

! <ET)
Inappro­
priate
feeding
and
weaning
practices

/

'■'X Community

Salmonella

Absent/inadequate/unsafe
sanitation

*•

Population

Community

»

Public health
O Safe Water Supply
O Better Environmental/
Sanitation
O Improve Milk/Food/
Water
O Personal/Community
Hygiene
O Health Education
O School Health
O Vector Control

> Commutity health
O Tackle Poverty/
Marginalisation
O Poverty Alleviation
Programmes
O Environment and
► Health Campaigns
O Hia/Eia of Develop­
ment Strategies
O Pro-Poor/Pro-People
Economic Policies
O Counter Commercialisa­
tion of Health Care

HIA/EIA Health and Envir<,.imentrl impact assessment.
Crypto­
sporidium
etc.

\

Campylo­
bacter

Individual

Clinical
Medicine
Diagnosis
Treatment
Prophylaxis

hygiene

'«

Rota virus

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Personal
hygiene

' Contaminated food
=£ Fly breeding in association with human or animal faeces
=> Inadequate health education or awareness building measures, or
=> Lack of access to basic or primary health care
• This wider understanding of the determinants of diarrhoea diseases
should help to shift the focus o * community based diarrhoeal disease
control strategics from oral rehydration and rational therapy including
reduction in the misuse or overuse of irrational anti diarrhoeals in the
market; to more social and community oriented strategics that include
=> Better environmental sanitation
=> Provision of safe water supplies
Measures to improve food, milk, and water hvgiene
=> Health education focussed specially on vulnerable groups
including women and children
=> School health as a focus of health-hygienic habits building
strategies
=> Vector control

Inadequate/
unsafe water supply

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Access to !
PHC

• W ith increasing involvement of the behavioural sciences researchers
in problem or situation analysis, which would include
=> Knowledge, attitude, practice surveys
=> Anthropological and ethnographic studies
=> Community dynamics and political economy studies
=> Operations and action research
Further understanding of the socio-economic-cultural-political
(SEPC) realities and context of the diarrhoea problem in the
community and the country will emerge.

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Poverty

fl

Inappro­
priate
feeding
and
weaning
practices

Vibrio
cholera

1i
5 ggz

E. coli. (E.P.)

Community
\ hygiene

Shigella

E. coli
(ET)

• JDIARRHOEAL
* DISEASE
CONTROL

Rota virus

" Crypto­
sporidium
etc
Access to
PHC

o

T5 HZ

£ Q-

CD CD

Campylo­
bacter

Absent/inadequate/•
unsafe sanitation

Resistance of primary health care/
public health system

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affecting access and affordability
Finally commercialisation of medicine that will develop a
vested interest in the abundance of ill health’ including
diarrhoeal disease promoting unethical, irrational remedies all
r

Contami­
nated
food

3b »

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Malnutrition

a

Ms
S’ S.2

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FLY/Vermin
breeding

Personal
hygiene

CD TJ
V) C

h

=4 Nc . economic policies that downsize government funding or ** ,
ivatise, liberalise or commercialise public health services

Pe.=
al/
displacement

Inequality/
marginalisation

Salmonella

op

/

<1
CD

Inadequate/
unsafe water supply

Economic policies LPG/
privatisation

There is urgent need for researchers to move beyond the biomedical
paradigm with its focus on molecular biolog}’, intracellular pathogens and
specific ‘magic bullets’ be they drugs or vaccines to a more wide angled,
multidisciplinary socio-epidemiological research strategy that focusses on
population and community determinants of the incidence ot disease.
• This comprehensive SEPC analysis will help us to understand the
social risks and community determinants of the diseases which will
include
=> Poverty, inequality^ and social marginalisation
=> Migration and displacement
=> Ecologically hazardous or unsustainable development
Structural, operational and technical resistances of the public
health and primary health caresystem
=> Development strategies without health impact assessment

as components of the problem '•
• Thr. late Prof. Geoffrey Rose calls this shift the population strategy
— ‘‘an attempt to control the determinants of incidence, to lower the
mean level of risk factors, to shift the whole distribution of exposure
in a favourable direction. In its traditional public health form, it has
involved mass environmental control methods; in its modern form
it is attempting (less successfully) to alter some of society’s norms o^
behaviour”.
• He goes on to add that its advantages are “radical; large potential for
copulation; and behaviourally appropriate while its disadvantages are
small benefit to individual (the prevention paradox); poor motivation
of {he subject; poor motivation of the physician; and a worrisome

benefit-risk ratio”.
• The need of the hour is to move not only from the individual strategy
to 3 population strategy (which is definitely the first step) but an even
more urgent additional paradigm shift from ‘population’ to
comm uni ty/people, where they become the centre of the act* on or
programme initiative and solution.
Community
People as Participants
Education/Social Process/
Basic Needs
Enabling/Empowering
Strategy
Socio Epidemiology

Individual
People as Patients
Drugs/Vaccine/On.
Providing Service

Intracellular
Moleculr Biolog)'
'—
So//re :CHC 1987.

• Un-ess we are able to make these shifts in our perceptions of the
problems, research in the country will continue to be ‘part of the
orcblem’ and not ‘part of the solution’. The laboratory to the. field
transfer of high quality ongoingresearch in the country awaits this
paradigm shift.
• A new partnership awaits> to be operationalised. The partnership
between the medical/laboratory researcher; the public health

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engineer; the social scientist; the cbmmurm
1th activist; and the
empowered community. Only such a partnership can ensure that
diarrhoeal disease control strategy will begin to make a dent on the
problem.
IS THE RESEARCH COMMUNITY IN OUR
COUNTRY
READY TO ACCEPT THIS CHALLENGE?

Community Aspects of Diarrhoeal
Disease Control
Merges F. Mistry1, Tannaz J. Bm2, Noshir H. Antia3
The Foundation for Medical Research and
The Foundation for Research in Community Health
Worli, Mumbai

Water related infectious diseases encompass a wide spectrum of etiological
agents ranging from the ubiquitous coliforms that cause diarrhoea to the
hepatitis and Chlamydia, hook-worms and guinea worms, schistosomes,
leishmama and filaria to the recently identified members of the
Mycobacterium avium complex. Whilst diarrhoeal diseases are the single
largest cause of mortality in infants and children in India (1.5 million
children under five years), morbidities from water related infections have a
profound effect through causation of under/malnutrition as well as affect
the IQ of chronically affected children. It is computed therefore that India
loses about Rs. 36,600 crore per year due to water related diseases. The
subject of controlling water borne infections is inseparable however from
the more overwhelming problem of chronic water scarcity that a majority
of our population faces from year to year. Though the 9th Five Year Plan
aims to provide drinking water at Rs 40,000 crores, 2,00,000 villages
continue to have acute drinking water problems.
The Ministry of Water Resources in a report of 1999 documents a drop
in water availability of about 66% (expressed as cubic metres per person
per year) between 1951 and 1999. This ever increasing shortfall is due to
pollution, over use, lack of conservation practices and increasing
population. M.S. Swaminathan berates industries particularly for drawing
water indiscriminately and feels that much of the problem is because there
is no Ground Water Act” in place. Nevertheless the seven water pollution
control laws that are in place today are confusing and many a times
contradictory.

1. Senior Scientist
Trustee
2. Senior Scientist
3. Director and Trustee

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304

'rhe Foundation for Medical Research
The Foundation for Research In
(.onimunity Health
The Foundation for Medical Research
The Foundation for Medical Researc i
The Foundation for Research in
Community Health

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