The neglected issue of drowning

 

It’s been 17 years but 77-year-old Admiral Purushottam Dutt Sharma remembers the day in November 1997. “It always brings a lump to my throat,” he says.

At 9 a.m. on November 19, 1997, a bus meant for 55 children but packed with 75, crashed over the rails of the Wazirabad bridge across the Yamuna in Delhi. It fell into the river and came to rest on a sandbank, windows above the water. Some of the students in the bus were in shock; some somehow got out and swam to safety, but some drowned. Nearby fishermen found and carried most of them to the sand bank, where they were laid in a neat row with schoolbags heaped on one end.

Twenty-nine children died that morning.

“A 10- or 15-year-old need not die on account of a brief period of immersion. All that was needed was attention from an adult by way of CPR (cardiopulmonary resuscitation),” says Sharma. “That was not acceptable to me. Children are our responsibility and their safety and protection is our concern as adults. If we fail, it’s a sad comment on our responsibility. That day we adults failed miserably.”

The idea of teaching lifesaving skills for children and adults was born that day in Sharma’s heart. Within a year, he commissioned the Rashtriya Life Saving Society (India)—the RLSS(I)—an organisation devoted to imparting life saving skills to children, adolescents, teens, and adults. It trains handicapped children too. The organisation is headquartered in Pune, with offices in Noida, Hyderabad, Kolkata, and Mumbai.

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here are many ways to die. Some are more shocking than others, like plane crashes, bomb blasts, and shootings. They get a lot of press, initiate discussions on TV, and fade from public consciousness, coming into focus only when the next tragedy occurs.

Some deaths are less so: traffic accidents, drowning, burns, falls, and poisoning. They don’t get a lot of press, and don’t register in public consciousness. Unintentional and accidental, these deaths are mostly personal in their corrosive effects of grief and often commonplace in their occurrence. The survivors often carry disabilities that can stay with them their entire lives

Drowning and lack of first aid is an open-ended health hazard across the globe, especially Asia. As Sharma says, 43 people drown every hour, every day across the world. In Bangladesh, 40 per cent of child deaths below the age of five are caused by drowning. Twenty-three per cent of all drowning deaths
occur in India.

The World Health Organization (WHO) released its first ever “Global Report on Drowning” on November 18. It defines drowning as “the process of experiencing respiratory impairment from submersion/immersion in liquid”. Terming drowning a global burden, the report states that “children aged under five years are disproportionately at risk and males twice as likely to drown as females. Over half of casualties are aged under 25 years”.

The report says that, “Drowning is a serious and neglected public health threat claiming the lives of 372,000 people a year worldwide.” And, “more than 90 per cent of these deaths occur in low and middle income countries”.

According to the paper by J. Jagnoor and others titled “Unintentional injury mortality in India, 2005: Nationally representative mortality survey of 1.1 million homes”, drowning caused over 70,000 deaths in 2005, with rates higher among males than females, and with a large proportion among children below the age of 15.

The report says that in 2005 unintentional injury caused 6.48 lakh deaths (7 per cent of all deaths, or 58 per  lakh of population). Unintentional injury mortality rates were higher among males than females, and in rural versus urban areas. Road traffic injuries (1.85 lakh deaths, 29 per cent of unintentional injury deaths), falls (1.6 lakh deaths, 25 per cent) and drowning (73,000 deaths, 11 per cent) were the leading causes of unintentional injury mortality, with fire-related injury causing five per cent of deaths. The highest unintentional mortality rates involved those aged 70 or older (410 per lakh population).

One of the conclusions of the report was that “these direct estimates of unintentional injury deaths in India (0.6 million) are lower than WHO indirect estimates (0.8 million), but double the estimates which rely on police reports (0.3 million)”.

According to the National Crime Record Bureau’s 2012 report, every day 76 people drown in India on average. “Drowning deaths are preventable except in cases of suicide and murder,” Sharma says, grieving over the “attrition of our youth”.

Professor Prabhat Jha, founding director of the Centre for Global Health Research (CGHR) at St. Michael’s Hospital in Toronto, echoes the sentiment. He is the man behind the Million Death Study (MDS) which seeks to determine the causes of premature mortality that so often happen away from medical attention and hospitals. The researchers, in collaboration with the Registrar General of India, are monitoring “nearly 14 million people in 2.4 million nationally representative households in India between 1998-2014.”

The latest results of MDS will be released in a month or two. “Almost all  these (drowning) deaths are avertable,” Jha says.

The lack of attention to this pervasive yet ignored issue infuriates Sharma. “At the Centre, no one cares a damn,” he says. “Drowning figures are ‘guesstimates’, counting only those reported to police stations or picked up by the media. We need more authentic figures.”

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etting authentic figures of drowning deaths has always been a problem in countries where they occur the most. Dr Michael Linnan is technical director of The Alliance for Safe Children (TASC), Thailand and the US. 

He says, “There isn’t good data on how many children drown in different countries because most drowning occurs in low and middle income countries. In these countries, fatal drowning is not reported to health facilities, so the large majority go unreported and thus uncounted by officials in the country.”

He points out that “in most low and middle income countries, the majority of children under five drown within 50 metres of the home and children five years and older drown further from the home—most within 500 metres.”

While under-reporting or non-reporting of drowning deaths exists due to various factors—one reason could be parents being blamed for carelessness—the way drowning occurs and the causes of drowning are many.

Children in Bangladesh are at high risk. Crisscrossed by three major rivers—Padma, Meghna and Jamuna and their tributaries—it is the world’s largest delta and has innumerable water bodies, including ponds, ditches, lakes and canals. It’s common to find a pond or ditch adjacent to each house in rural Bangladesh, says Dr Aminur Rahman, director of the International Drowning Research Centre and Centre for Injury Prevention and Research, Bangladesh (CIPRB), both in Dhaka. They are used as a source of water for everyday needs, but these, he says, are hazardous places that lead to drowning. 

According to the Bangladesh Health and Injury Survey (2005), drowning is the leading cause of death for children in the age group of one to 17 years, with about 18,000 children drowning every year, or 50 a day. Children in the age group of one to four years are the most vulnerable; about 12,000 children in this age group drown each year.

Rahman relates stories of how drowning occurs due to various causes and how it unfolds. In one instance, two brothers—10-year-old Hassan and five-year-old Hossain—from a village in Raiganj subdistrict of Sirajganj district in Bangladesh, went to a playground after school to play football with other village children. When it got dark and the children hadn’t returned, their mother Amina became frantic. None of the other children could tell her where the brothers went after the game.

Neighbours started looking for the boys. Unable to find them anywhere, they decided to search a nearby pond. That was when a fishing net was thrown into the pond and the two boys were recovered, both dead. The exact cause is not known. It’s postulated that Hossain fell into the water and his older brother tried to rescue him but both drowned.

This type of drowning, Rahman says, is called twin drowning. Amina, the victims’ mother, had said that her older son could swim. But usually in rural Bangladesh, children learn swimming informally, either from their peers or from relatives, none of whom are trained instructors. As a result, Rahman says, children do not learn rescue skills. So when such swimmers attempt to rescue, both the victim and rescuer’s lives become threatened.

Rahman recounts another instance of drowning. In July, a three-year-old boy named Ariful drowned in a pond near his house in a village in Raiganj. Ariful’s father, Abul Hasem, is a rickshaw-van puller. On that day, Ariful went to market with his father. He was in the rickshaw and his father was pulling it. On the way back home, they saw villagers and children bathing in a pond nearby.

Ariful wanted to join them. His father said no, but Ariful insisted on going into the water. Abul finally agreed, placed the rickshaw aside, and father and son went into the water. Ariful started playing with the other children, Abul watching over them. When Abul finished bathing, he climbed up to the bank of the pond and started drying his hair with a towel. It occurred to him that he should dry Ariful’s hair too, and he turned to ask him to come out of the water.

But he could not see him. He asked the other people in the pond; someone said he might have gone home. Two villagers dove into the water, but could not find Ariful. Abul Hasem dove four times into the pond. On the fourth attempt, he touched one of his son’s legs with his hand, grabbed the leg, and pulled him out of water. The child was dead.

In this instance, Rahman says, just a brief absence of supervision caused the tragedy.

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rowning victims die of suffocation or asphyxiation. Water fills the airways, blocking oxygen supply to the body, progressively depriving organs of oxygen, finally leading to brain death.

In wet drowning, which estimates suggest is 80 to 90 per cent of all cases, the victim sinks and reflexively holds his or her breath. The victim surfaces to take a breath, sinks again, tries to surface, and struggles as he/she becomes weak. The weight of the head feels heavier and heavier, leading to further sinking.

During this sinking and surfacing, the need to breathe becomes acute, and the person ingests water. There are chances that the person may throw up, only to swallow the vomit with his or her gasping. At a critical point, the person gasps, inhaling water into lungs. A struggle follows until the gasping ends, respiration fails, the heartbeat goes haywire, the heart stops beating, and the brain dies.

In dry drowning—estimated at 10 to 20 per cent of cases—the victim inhales water into the larynx or trachea. That sets off a horrific contraction of muscles, closing off the airways. Lungs struggle to maintain air pressure inside with respect to the outside in sync with the movements of the diaphragm and chest muscles. Since the airway is shut, air cannot enter from outside. Blood is sucked from the pulmonary capillaries, filling empty cavities in the lungs, which destroys them. In the meantime, mucus and inhaled water combine to form froth which further blocks the airway. In the end, the brain dies.

Because the series of physiological calamities occur through spasms of muscles and closing off passageways, and water doesn’t enter later on as in wet drowning, it’s called dry drowning,

Even if the victim is pulled out of water, and resuscitated, there is a danger of another calamity called secondary drowning. Children are especially prone to this. When the person has seemingly recovered, the lungs absorb inhaled water along with all the contents, leading to gasping, wheezing and other complications. If the victim is not treated, lung injuries are severe, leading to Acute Respiratory Distress Syndrome (ARDS) and permanent damage.

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he calling of researchers like Rahman has been compiling the ways of drowning and how to prevent them. After a medical degree and a post-graduate diploma in public health, Rahman took up teaching and public health research in 1994. Inspired by his senior colleague, Professor A. K. M. Fazlur Rahman, he has researched prevention of drowning since 1999.

As a principal investigator, he conducted the Bangladesh Health and Injury Survey. “I decided to devote myself in conducting child drowning prevention research to find effective interventions to save thousands of children’s lives in Bangladesh and other similar settings.”

Another researcher at the front end is Professor Adnan A. Hyder, director of the Johns Hopkins International Injury Research Unit, a WHO Collaborating Centre for Injuries, Violence and Accident Prevention. Established in 2008 within the Johns Hopkins Bloomberg School of Public Health’s department of international health, the Unit conducts research and responds to the growing burden of injuries worldwide.

“We work to identify effective solutions to the growing burden of injuries in low- and middle-income populations, influence public policy, and practice and advance the field of injury prevention throughout the world through research, collaboration and training,” Hyder says.

Hyder is also the director of the Health Systems programme within the same department. The programme works “to design systems and implement equitable and cost-effective strategies for delivering health care and health promotion interventions to disadvantaged and underserved communities in the US and abroad. The principal goal of Health Systems is to improve the capacity of communities to deliver the best possible preventive and curative care to their respective members.”

Hyder grew up in Karachi, graduated with a medical degree from Aga Khan University, and then moved to Baltimore in 1992 for graduate school at the Johns Hopkins Bloomberg School of Public Health, where he received both his Master of Public Health and his Ph.D. Growing up in Karachi, he saw first-hand the disparities between middle class communities (where he grew up) and the urban slums, where health care was horrifically inadequate.

His first job out of medical school was with Aga Khan Health Services in Gilgit, northern Pakistan, as manager for a primary healthcare programme. On the job, he “witnessed the kind of severe injuries that were so traumatic as to be beyond help” because of the terrible state of the roads. Sometimes they were one-way roads, thousands of feet up with no guardrail. The injuries were such that even getting these victims to a better hospital would not have been helpful. That’s when he became interested in ways to prevent injuries in the first place.

“We understand how to prevent disease, but injuries? Twenty years ago, little was known about the epidemiology of injuries in developing countries. The science was missing, and that’s what I became interested in.  And to me, injury prevention felt like a natural progression of my interest in social justice and inequalities in health,” he says.

When Hyder first joined the faculty at the Bloomberg School 15 years ago, he says there weren’t many people studying drowning in the developing world.

“But given what we did know, that drowning was one of the leading causes of death for young people in low income countries, it seemed like an area that needed attention.”

Hyder points out that estimates suggest that 90 per cent of drowning incidents occur in developing countries, specifically in countries in Asia—Bangladesh, Vietnam, Cambodia and some provinces in China. Understanding the risks associated with drowning is key.

In low income settings, he adds, lack of physical barriers between a child and a water hazard, as well as a lack of (or inadequate) supervision of very young children can contribute to an increase in drowning risk.

Uncovered or unprotected water supplies (like an open cistern or a pond in the home) are other potential risk factors. The risk is highest among children in the age group of one to four because of their curious nature, yet they are too young to acquire swimming skills.

“The problem is that there has not historically been very accurate information available on the causes of drowning in low income countries and without understanding what is really causing children to drown, we cannot implement effective interventions,” he says.

With what they do know, researchers and NGOs are working to prevent drowning.

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ot a man to leave deaths unaccounted and uncared for, Sharma is writing  to district collectors and superintendents of police of each of the 674 districts in India to obtain drowning figures.

In the way of prevention of drowning, his organisation RLSS(I) instituted the “Swim and Survive” programme. It started in Kerala with the state government’s support, moved into Karnataka, and is now trying to make inroads in Maharashtra. The programme works on managing pools and teaching swimming and lifesaving skills through portable pools.

Sharma says drowning deaths are increasingly common among adolescents and those above 18. “Kids think they’re invincible; they don’t wear helmets, their safety consciousness is minimal.”

Sharma started the RLSS(I) with initial financial support from the Tata Trust, and he accepts help from the right people. Municipal corporations that pitch in for lifesaving skills for people, as in Kerala, pay the costs. The organisation hence saves on money collected, and extends its services to new locations. Over the years, it has taught life-saving skills to 1.5 lakh people, and swimming to 45,000-55,000 children, including handicapped children.

In addition, RLSS(I) is training the State Disaster Response Force in Andhra Pradesh, which worked with the National Disaster Response Force to save many lives in the recent cyclone that hit Visakhapatnam.

Sharma says many little things can be done to prevent drowning. He suggests learning to swim early; fencing and barriers around pools, canals and other water bodies close to paths and roads; wearing lifejackets when on water; training in flood rescue and survival; learning lifesaving drills on land and in water, and so on.

In Bangladesh, Rahman says the CIPRB conducted a community trial—Prevention of Child Injuries through Social Intervention and Education (PRECISE)—on a population of 6 lakh in three sub-districts between 2005-2010. The programme was a collaborative effort by CIPRB, UNICEF Bangladesh, The Alliance for Safe Children (TASC), and the Royal Life Saving Society, Australia (RLSSA).

PRECISE had two major interventions: Anchal (a community day care centre) for children one to four, and SwimSafe (survival swimming teaching) for children four to 10. The evaluation of PRECISE shows Anchal is 80 per cent protective and SwimSafe 96 per cent. This means, he says, children who participate in Anchal are 80 per cent less likely to drown than those who do not participate; those who participate in SwimSafe are 96 per cent safer.

Dr Linnan says SwimSafe is jointly developed by TASC, RLSSA, and a local partner in each country they implement it in. The largest is in Bangladesh, where their partner is CIPRB. He adds that with its two components—village crèches for children aged one to four, and SwimSafe for children aged four to 16—the programme covers children in the age group of one to 16.

After the successful completion of the PRECISE trial, CIPRB developed the International Drowning Research Centre, Bangladesh (IDRC-B) in 2010 as a part of CIPRB, with the support of RLSSA, TASC and AusAID, in order to develop further research on drowning.

According to Rahman, IDRC-B has evidence that teaching swimming does not increase water exposure or risk-taking when in water; SwimSafe children can rescue others—the criteria for SwimSafe graduation are the ability to swim 25 metres, floating for 30 seconds, and rescuing other children if they accidentally fall into and begin to drown; and the first responders can learn the skills and knowledge of first aid including CPR and can retain those skills and knowledge for a considerable time.

However, drowning in floods and in boat capsizes are regular phenomena in Bangladesh. There is a dearth of information about these deaths. In recent years, Rahman says, the main causes of death during floods were drowning (70 per cent), snakebite and electrocution.

As the socio-economic, environmental and cultural context of Bangladesh and India are almost the same, Rahman suggests that prevention measures found effective in Bangladesh could be useful in India. The following interventions could be particularly useful: raising awareness of children, parents and the community on drowning and its prevention; institutional supervision (as Anchal in Bangladesh) of children under five; teaching survival swimming skills to children aged four and over; teaching lifesaving skills including CPR to community people.

Hyder’s team, which includes Dr Kunle Alonge who grew up in Nigeria, is also working in Bangladesh along with the International Centre for Diarrhoeal Disease Research and CIPRB, on the Saving of Lives from Drowning project, funded by Bloomberg Philanthropies. The unit is trying to quantify the burden of drowning and implement interventions to prevent drowning among under-five children.

The project implements both playpen and crèche interventions during a two-year period in seven rural sub-districts in Bangladesh. It delivers either a playpen or the opportunity to attend a crèche, or both, along with family education and community awareness programmes to an estimated 80,000 children between the ages of nine months and four years.

“We are hoping the study will show us how effective these two methods will be as primary prevention strategies. It will also help us understand implementation challenges and the processes necessary to roll out such interventions on a large scale in other low and middle income countries (like India, for example),” he says.

Hyder says the project is still in the early stages but initial results are encouraging. The leading cause of injury death for all ages (adults and children) in Bangladesh, he points out, is drowning. Out of every 1 lakh children under five in the country, 100 will die annually from drowning if nothing is done (50 per cent of those will be boys). That’s almost 15,200 children under five.

“By implementing these two interventions, we hope to save lives every year,” he says. Both of these interventions have a high rate of acceptability and the communities are actively involved in delivering and monitoring these interventions.

As for India, Hyder says it’s important to understand the root causes of drowning in specific locations. “India will need to understand the causes of drowning and focus on interventions.”

Based on their studies and research on risk factors and interventions in Bangladesh, Hyder says, “We can work to develop potentially similar interventions for other countries, including India. Barriers around water bodies, safe places for children, training community members in safe rescue, developing a national water safety plan—these are some of the useful things. But we will emphasise cultural acceptability and appropriateness.”

Hyder pitches for more research on drowning. “We need more data, studies to test proper intervention packages, and continue exploring culturally sensitive solutions. For well-established interventions, adapting them to local culture and scaling them up in developing countries is a big issue. We also need to explore technology and mobile health solutions, making the best use of modern technology.”

Prabhat Jha specifically mentions open wells that swallow lots of children in India.“The main effort, which along with Prime Minister Modi's efforts on ending open defecation and improving water and sanitation, would be to ensure open wells are banned, and all will have some safety training. Expanding basic life support/CPR skills to primary health care workers can also reduce mortality among children with near drowning.”

Interventions to prevent drowning are best done by engaging local community. Justin Scarr, drowning prevention commissioner, International Life Saving Federation, and CEO of the Royal Life Saving Society Australia, says, “The interventions almost always involve local staff or volunteers, crèche workers, swimming instructors, community organisers so the opportunities to contribute to community well-being are high.” 

He adds that there are aspects of drowning prevention where the government must play a role, notably legislation and enforcement of shipping safety standards, ferry passenger limits, and use of lifejackets. Scarr says governments in South Asia have taken a limited role currently in assisting NGOs and communities to prevent drowning, though there is evidence that this is changing with governments recognising data showing the burden of drowning on communities, particularly children.

With an estimated two-thirds of the world’s drownings in Asia, Scarr says, “Asia’s rapid economic growth and development means the world is looking towards Asia for drowning prevention leadership across the next decade.”

It was one tragic incident 17 years ago that launched Sharma’s mission, and the mission continues. “There is so much one can do to reduce drowning,” he says.