Title

A Mortality Survey of Epidemic Diarrhoeal Deaths in Kerala

Creator

K P Aravindan

Kerala Sasthra Sahithya Parishad

Date

1989

extracted text

BACKGROUND PAPER VL
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COMMUNITY HEALTH CELL
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BANGALORE-560 001

A. MORTALITY SURVEY OF EPIDEMIC DIARRHOEAL DEATHS IN KERALA
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Kerala has attracted the attention of social scientists
the world over for its apparent paradox of health development
in the setting of economic backwardness. Kerala lags behind
most major Indian States in industrialisation and agricultural
production. The per capita income is below the Indian average
and the density of population is the highest in the country.
Yet, in general health indicators it is far ahead of the other
Indian States. The infant mortality rate of 34, the life
expectancy of 65, and crude death rate of 6.5 are strikingly in
contrast to the rest of India and comparable to those seen in
developed economies. The high literacy rate ( both male and
female), and the sex ratio nd life expectancy figures that
favour women are the other adjuncts of this health development.
A well developed public distribution system,extensive land reforms
high agricultural*wage, and the political power of the working
class are arguably some of thd /factors that have gone info the
making of this Kerala health miracle. Successive governments have
spent a considerable part of their budgetary expenditure on
education and health. The health care delivery system is developed
to such an extent that Kerala with 3.5% of India's population
accounts for more than 30% of the total hospital beds in the
country.

It is in this setting that the diarrhoeal deaths that
occured in the epidemic between November 1987 and January 1988
has to be seen. The toll of 300-400 deaths was definitely worrying
in the above mentioned social setting K.S.S.P. investigated
these deaths to gain insights into the problem. The prime question
was ' why so many deaths when deaths in these diseases are so
eminently preventable?'
METHOD

Names and addresses of the deceased wore collected from
the district health authorities. Trained workers of the K.S.S.P.
visited their homes with preset mortality survey proforma. 87
deaths from 8 districts were thus analysed.
f
THE FINDINGS
and Sax

Death occured mainly in the very young and the old.
Those below 5 years and those above 50 years of age accounted
for the most deaths, each group accounting for 38% of the total
deaths.
From information wo could gather from the various hospitals >
about one third of the stools tests were positive for vileris
cholera. The patterns of do...th ih the two extreme age groups is
thus consistent with the belief that the epidemic that ravaged
the State was indeed an epidemic of cholera.
. 57.5% of the deaths occured in women. The difference was
largely due to the deaths in the 16-40 years age group. There
were 13 deaths in this age group, women accounting for 11(85%).
Despite the higher life expectancy for women in Kerala, their
health status especially in the reproductive age group leaves
much to be desired and problems like anemia are very common.
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Preliminary home care

Withholding of liquids from patients with-diarrhoea is
said to be traditional oelief in many parts of India. We had
not expected it to be a problem in Kerala. We wire surprised
therefore to find that 40% of the patients received no fluids
or just enough to wet the lips nd mouth. ORS was given to 2%
only.
In the survey it was found that only 38% of the respondent
families knew that in diarrhoeal diseases more fluids have to be
given. Only 3% of the families had over heard of ORS. Only 4%
knew how to prepare the home remedy. It is a sad commentary on the
much vaunted literacy achievements of Kerala. Kerala has a vast
reading public. In the last ten years there has been an explosion
in publications. Even the lowest on the social ladder read
newspapers and the ubiquitous vernacular weeklies most of which
sport doctor's columns. But their staple fare has been imaginary
sexual problems rather than real health issues. The government too
has not done anything in the way of popularising ORS in any
sustained manner.
A district wise. an.lysis showed that it was in Malappuram
considered the most backward district- that ironically more
families knew about first aid in diarrhoea. Incidentally, in the
district some good work has been done in spreading the message of
immunisation and ORS ns part of the India population project.

The Health delivery systam
Of the 87 deaths studied 84 patients were hospitalised,
testifying to the wide and easy access to hospitals by all
sections of society. But the disturbing aspect is that this did
not prevent deaths. 2% /ere first admitted to Ayurveda hospitals
and "98% to various hospitals practicing modern medicine. Of
these 31% were in the private sector and 69% were'government
hospitals.-

One question that we examined was whether the deaths
were due to delay in hospitalisation.Unfortunately ths answer is
no because 47% were hospitalised within 3 hours of onset of
symptoms, 70% within 6 Lours and 88% within 12 hours. Any
hospital dealing in modern medicine is supposed to have facili­
ties for rapid rehydration of pati-nts with severe diarrhoea.
Yet the system failed tc deliver the goods at the critical
juncture. We examined some aspects of this failure.
48% of the patients were transferred from the hospital
where they were first admitted. 84% of these admitted in
private hospitals, 38% of those in PH centres.-md 50% in Taluk
Hospitals were subsequently transferred. Valuabletime thus lost
in transit may have been a contributing factor in their death.

The final hospital where the death occured included PH
centres (29%) ,Taluk Hospitals (19%),District Hospitals (30%),
Private hospitals (11%). Even in the Government hospitals 61%
had to spend money buying medicines from outside. Drips were
bought from outside by 34%, drip sets by 24% and ORs packets
liy’14%. Considering that medical service in Government hospitals
in the State are supposed to be free, this is an adequate
commentary on the perennial short supply of these items even
in the referral centres. No laboratory investigation was done
in 58% of patients.
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Another interesting finding was the interval between
admission and dealth in the final hospital. It was more than 24
hours in 74% of cases .nd more than 3 days in 31%. Inappropriate
rehydration measures resulting in electrolyte imbalances q,puld
have been a factor in many of these cases. Solutions like ’
.. Ringer Lactate useful in combating cholera were not available f
even in the district hospitals. The doctors are not. trained
adequately to deal with rapid rehydration. Laboratory support
to monitor such cases are almost non existant except in the
Medical College Hospitals.
;

The Socio-economic setting and.environment

95% of the deaths occured in those from the lower socio­
economic group as .judged'from the income, housing and other
parameters. 19% belonged to the scheduled castes who comprise
10% of the state1s population. But the literacy rate among the
family members of the victims was 74%, which, is comparable to’
.the-statewide figures. In other words these were people who could
have been reached by concerted health education programmes. The
gross neglected of this aspect of public awareness creation by the
audivisual and print media private and government is to be.seen
in retrospect as leading to this calamity.

Drinking water being the prime culprit in epidemics such as
this, the source of water supplv of the affected ■ families- was
enqjj*ired into. 51% used wells (50% public wells) mid 5% water
from ponds and canals. The most disturbing finding was that 37%
of the families use protected water supply from public pipes.
Inadequate chlorination,contamination from sewerage through
faulty and leaking pipes etc. may be possible causes of disease
spread in such cases. There is no system as yet for monitoring
water quality and detection of contamination by random checks.
Only 12% of the households had sanitary latrines, 69%
were defaecating in the open, n determined effort by the Government
to remedy this situation is yet to materialise.
CONCLUSIO N S

The achievements made by Kerala in the field of health
through remarkable, are built upon a fragile foundation. The
decrease in mortality figures are not accompanied by corresponding
decrease in Qverall morbidity. The drinking water problem is still
acute in many areas and wherev.-r it is provided it is by no means
safe or protected as claimed.. Sanitary conditions are woefully
inadequate for the vast majority. These arc- problems that have to
be addressed on a war footing.
The much hailed health services though possessing a. fairly
adequate infrastructure is -found wanting in crisis situations.
Lack of proper planning, chronic shortages of essential items,
wasteful expenditure, lack of continuous training of doctors
in essentials like rehydration are some of the problems which
have to be tackled.

The high literacy and the ■'■vid reading hatit of the
Malayalee have not been token advantage of in conducting health
education programmes. The urgency of the problem has net
adequately registered on the Government or the private print
media. Kerala is claimed to represent the model of health
development in the absence of economic advancement. This study
points” to some of the basic fl -_ws inherent in such a model.

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For us in the KSSP, this mortality survey is a guide to
future action. We express our gratitude to the bereaved families
who hove co-operated wita us to provide information and the
hundreds of activists who have been involved in this survey as
well as in subsequent follow up work.
GENERAL REFERENCES:

Statistics

1.

Government of Kerala, State Planning Board
for planning, Trivandrum,* 1983.

2.

United Nations, Department of Economic and Social affairs.
1 Poverty,unemployment and development policy, a case study
of selected issues with reference to Kerala,'New York, 1975.

3.

Panikkar P.G.K. Soman C.R., ’Health Status of Kerala.’
Centre for Development Studies, Trivandrum, 1984.

Dr. K.P. ARVINDAN
K.S.S.P.