The story of Nun Chini Pani

‘A Solution Worth Remembering.’
Innovative Communications and Oral Rehydration Therapy in Nepal

George McBean

gmcbean@hotmail.com

P1080349


In the early 1980s the population of Nepal was advancing through the 16 million mark and diarrhoea-related dehydration was the single largest killer of children in the country. Like a profile of a Himalayan mountain itself, the yearly graph showed a rapid increase in fatalities after the monsoon season began in May, with its pinnacle of deaths in mid-July and a downwards trend towards October. In all, some 45,000 children died each year,(Intercept Evaluation 1987) mostly from causes that could have been easily prevented by a salt and sugar drink known as oral rehydration salts (ORS). In the late 1990s, figures indicate a tremendous turnaround -- despite an increase in population to some 23 million, diarrhoea-related deaths are down to 30,000 each year. There is also a remarkable awareness of oral rehydration solution among 96% of the population. (Nepal Family Health Survey 1996 ) Many factors have contributed to this success, but central to raising ORS awareness was an innovative UNICEF communication initiative. The life saving drink ORS was discovered in Bangladesh in the 1970s after a cholera outbreak brought thousands suffering from dehydration to queue outside hospitals waiting for the then necessary intravenous treatment. The actual moment of discovery is obscure, but one version suggests that frustrated doctors began to hand out the packets of the salt and sugar intravenous-drip solution. Some people began to drink the solution and after a short time felt well enough to walk home. The fact that one could rehydrate the body quickly and orally through a drink of salt and sugar was confirmed by Bangladeshi doctors. This type of therapy and it's potential for saving the lives of dehydrated babies prompted the British medical journal "The Lancet" to announce ORS as "potentially the most important medical breakthrough this century". (5th August 1979)

The world responded to the discovery of ORS in several ways -- with the creation of rehydration drinks such as Gatorade for athletes and people with hangovers, as well as to the manufacturing of inexpensive packets of the solution for families in developing countries. Yet in the 1980s most people in Nepal remained ignorant of the discovery. This was not surprising really, since over 90% of Nepalese live in rural areas remote from roads -- where distances are usually measured in days of walking. Communication at a national level in the early 1980s was slow, if and when it was possible. There was no national television, relatively few radios, fewer than 20% of women could read and only an estimated 12% of Nepalese paid taxes. The remote location of Nepal's people meant that most relied on traditional healers for health care. At the time there were an estimated 400,000 of these Dhamis or Jankris who were mainly scattered through the hills and lowlands of the terai. Their proliferation contrasted sharply with the mere 600 registered doctors in Nepal and mainly based in the Kathmandu Valley. The Dhamis and Jankris were in great demand during the monsoon season, visiting about eight to twelve mothers each day advising them on what to do with their sick children. Unfortunately, their advice often proved fatal, since they generally advised parents to withhold liquids from children suffering from diarrhoea. Their logic was that if nothing went into the child, nothing would come out. For four months of the year an estimated 400,000 well intentioned faith healers were giving the wrong advice eight times a day to families in Nepal. Doctors on the other hand were generally giving the right advice about ORS and how it could save a dehydrated child from death. Having spent several years being trained as doctors, most found their clinics inundated with people during monsoon season either suffering from, or carrying a child with, diarrhoea-related illness. Coping with such "simple" diseases, they had little time to practice the "medicine" they had spent so many years learning. Moreover, the few doctors around were insignificant in comparison to the scale of the problem. Save the Children UK was aware of this discrepancy and had begun training both health workers and traditional healers in the treatment of diarrhoea.

The real cause of diarrhoea related illness in Nepal is known to be the unsanitary defecation practices in the hills and villages. During the monsoon, rain washes several months-worth of feces that have lain through the winter among the hillside shrubbery, into the waterways and drinking systems. Without changing the behaviour and access to sanitation facilities for millions of Nepalese, there will be a persistent reoccurrence of seasonal diarrhoea-related illness in the country. The protection of water sources, increasing access to latrines and education were and remain part of the government's plans and have strong support from UN agencies and non government organisations. Yet progress has always been slow and expensive for a country that possesses the equivalent annual budget of one medium size university in the United States. In the mid 1980's, UNICEF recognised that a formidable communication challenge existed to try and reduce as quickly as possible the number of child deaths related to dehydration. Only an estimated 2% of the population of Nepal outside the Kathmandu valley knew anything about Oral Rehydration Salts. The machines to manufacture ORS packets had been installed in the capital and the product known as Jeevan Jal was being manufactured, distributed and sold but still in very limited quantities.

From a communications perspective, it was first necessary to target traditional healers in a nation wide campaign, to help them to get their information correct and at the same time inform them about ORS. Logical? Yes! Easy to implement? No! There was no leader or "Pope" of Dhamis and Jankris whom one could approach in order to change their practices quickly. There was also stern opposition to even attempting to reach these traditional healers -- from government and from the medical profession itself. Why, we were asked, are you focusing on traditional healers? They are dangerous quacks. Instead, we were told, UNICEF should help governments build up their medical and health infrastructure. We should be training nurses and health workers.

UNICEF argued that this was already happening, but at a slow pace and was highly dependant on sizeable donations from outside the country. We also argued it was important and worthwhile to try and change the messages that traditional healers were giving to parents about the treatment of diarrhoea. We were not trying to make traditional healers into brain surgeons, we simply wanted to target them in our communication drive for ORS and alert people to the dangers of withholding liquids from a dehydrated child. We also wanted to increase the use of oral rehydration therapy by promoting a home solution of ORS called Nun Chini Pani (Salt, Sugar Water) One handful of sugar, plus a three finger pinch of salt in three tea-glasses of water was agreed to be a reasonable rehydration mixture. Here came another wave of objection to the initiative and this time more fierce since it was internal, within UNICEF. The manufacturers of the ORS packets of Jeevan Jal, a project also supported by UNICEF, suggested that we should not stress home solution Nun Chini Pani, because it would reduce the sales of Jeevan Jal. It was also likely that people would not mix the home solution properly. Since the packets were simpler to use than the home-solution, it was suggested that the communication campaign should centre around the promotion of Jeevan Jal.

Yet for the communication team the argument and figures did not add up. Packets of ORS were available to less than one eighth of the country but the main ingredients, sugar and salt, were available in every village and in an estimated 80% of households. To base the communication message on an ORS packet that so few could obtain would damage the credibility of the initiative. Far better to choose the promotion of the home solution ORS and let people make the connection in their own minds. They would choose the more easily made packets if and when they became available and in fact lead to an increase in sales. The message about home solution ORS would however need to be relevant to everyone and allow us to appeal to the public to help us spread the news as a valuable piece of information.

The Nun Chini Pani initiative was started with the launching of a song on Radio Nepal. (Nothing particularly innovative about that.) The song was performed by a popular singer and accompanied by several messages on how to mix the solution at home. Part of the radio message's appeal however was the announcement that it was up to the audience to help with this; an invitation for people to join in and spread the knowledge of ORS to save children's lives. It is interesting to note that many of the best ideas for the promotion of Nun Chini Pani came from the public themselves.

One suggestion was a unique way in which to reach the traditional healers. Why not train retiring Gurkha soldiers in the preparation of Nun Chini Pani, before they returned to their villages in the hills as well-respected members of the community. They could in turn gather the local traditional healers together and teach them how to mix Nun Chini Pani. This idea had the potential for mass mobilisation. Over a period of three years with the approval of the British and Nepalese Gurkha Regiments, retiring soldiers did this in a most effective way. Among their tools was a special memory card, distributed to traditional healers, that showed visually how to make the home solution. Hundreds of thousands of the sturdy Nun Chini Pani memory cards were printed and it is likely that most survive to this day -- since we printed an image of Durga, the favourite god of traditional healers, on the back of the card.

Other innovative ideas included cloth printed with visual instructions on how to mix ORS that was used to make umbrellas for health workers and Gurkhas, for curtains in health posts, hats, shirts for young mothers and small vests so that children visiting a clinic would be given a vest with the instruction for ORS across the very stomach that was suffering. Posters were prepared with life size illustrations of both the amounts of sugar and salt as well as the size of glass required for the mix. People could measure the size of the glasses used against the poster. Two of Nepal's most famous comedians Madan Krishna and Hari Bunshar adopted the campaign and put Nun Chini Pani instructions on their audio tapes, in their live shows, on their radio programmes and on videos of their puppet performances. A local football team manager named his team Nun Chini Pani and published their scores each week in the local newspapers. At the height of the initiative, with the help of an NGO, World View International, over 100,000 people were training others how to mix home solution ORS. Radio Nepal had informed and instructed countless others with broadcasts of up to six messages a day. The Times of London reported on the Gurkhas involvement (6/12/86) and the Queen of Nepal, unprompted, would often refer to other social messages that "need to spread like Nun Chini Pani."

Aside from the more innovative ideas mentioned above some standard communication products were made, including stickers, flip charts and comic books. These however were accurately designed after a study of "visual literacy" was carried out with Nepalese people in rural areas. As is now well-known, people who are non-literate and unused to receiving messages from pieces of paper often have difficulty interpreting visual images. The innovation of the Nepal study, however, was that it measured how quickly people could learn to understand pictures, especially if such "tricks" as perspective and sequence were briefly explained. Researchers made 10 visits to 460 respondents in 16 villages, testing their reactions to simple line illustrations, measuring how much people's visual awareness skills improved after they were taught how to "read" pictures, as opposed to those in the control group who were not taught.

The study "Rethinking visual literacy. Helping pre-literates learn," helped the designers of the visual components of the project to produce more appropriate materials but has since been referred to as "perhaps the most important visual literacy study ever carried out" by author Bob Linney in his book "Pictures, People and Power." The study has since been used to guide the production of many other community level publications for pre-literates. Most of the illustrations are now contained on a UNICEF Illustration CD Rom (Containing over 3,000 development line drawings.)

One interesting off shoot of this research was the discovery of the power of animation on pre-literate audiences. Moving animated images which portrayed comic characters and helped to explain how things worked, had the ability to immediately capture an audience's interest. This was especially true of sensitive subjects such as sanitation, abuse and sexual behaviour. The format had far more impact than a live action documentary style. The Nun Chini Pani project therefore adapted the artistic talents which lie abundant in the main cities of Nepal, to the medium of animation. The first locally produced animated film in Nepal was made on the subject of ORS. This aspect of the project captured the imagination of many decision makers. The television spot was later followed by a longer production on sanitation, distributed on tapes to community viewing halls and shown on Nepal TV when it finally arrived in 1986. (This initiative in animation has since spawned an approach to communication used by UNICEF programmes in South Asia, Africa, Latin America and the Caribbean, and in a global partnership with over 80 animation studios.)

A mid-term evaluation in Nepal conducted by Jon Snow International helped to refine the ORS communication initiative in its final years. At that point it was too early to relate any of the communication activities to a drop in the mortality rate for diarrhoea related deaths. It did however, recognise the unprecedented scale of the communication effort and recorded that already more than half the Nepalese population had become aware of ORS. Also, as predicted, the sale of Jeevan Jal packets were steadily on the increase, benefiting from the overall awareness of ORS promotion and assisted by the fact that it was easier and more effective to mix the packet, whenever one could buy it. The study also pointed out a down side to the Nun Chini Pani initiative, that the home solution was not guaranteed to be mixed properly by everyone who was taught and neither was it sustainable as a communication effort (as is the case for most home remedies and solutions).

At a cost of US$300,000 over a period of four years the communication initiative was designed in its later period to become sustainable through the sale of packet ORS. The revelation that rice-water, which was available in most homes, was also a viable rehydration drink and therefore deserved equal publicity as Nun Chini Pani came late in the campaign. Breast-feeding a dehydrated baby (possibly the ultimate home remedy for many infant illnesses) was also competing for communication funding. Because there was no return of any money for the distribution of this information there were little funds available for continually publicising the home solution messages. It became clear that with the increased commercialisation in information and advertising reaching rural areas the long term solution to diarrhoea related deaths (aside from improving sanitation) was the widespread promotion and availability of Jeevan Jal packets.

The Nun Chini Pani communication initiative ended after the awareness level of ORS had reached a critical mass and was institutionalised as much as possible in the practice of traditional healers, health professionals and school teachers. Although still subsidised, ORS packets nowadays have at least the potential for paying for their own increased manufacturing and public awareness support in Nepal - and for saving lives.

Lessons learned in the course of this initiative provide some help (but no recipes) to communicators who are now tackling new issues such as awareness of Vitamin A, Iron deficiency and other nutritional challenges in developing countries. First, with every new discovery there is the communicator's challenge of separating the information required for public acceptance, from the product that could bring the benefit. (I believe it was William Randolph Hearst who once said "News is something someone somewhere wants to suppress. All the rest is advertising.") The "news" aspect of a new medical or scientific discovery can be effectively used to mobilise massive support for disseminating information. People are willing to spread the news, debate the issue, or join up to support the cause. That's exactly what Nun Chini Pani was at that time in Nepal, news. No one had heard of ORS before, just as they know little of Vitamin A now. The Nun Chini Pani message appealed to the common person because it offered them knowledge they could share and trade with others. It was observed (although not scientifically) that few would have joined in to help spread the message of Jeevan Jal ORS packets at that time because it was perceived negatively as helping a manufacturer make a profit.

The second lesson is that, however successful you have been with spreading the news and in mobilising assistance, if this "new" information is not internalised into the practice and educational programmes of key institutions such as schools and health services, the effort and its impact will be short lived. When dealing with "pure information" through the mass media one needs to seek ways of paying for the message. One way of overcoming the "old news" phenomenon is to relate the information whenever possible to a product. Adverts and radio spots for the ORS packet Jeevan Jal are now keeping the awareness of ORS in the public eye, in much the same way as products in the West, advertised to help people quit smoking, keeps the idea of "quitting" continually in the public eye. (Who needs to compete against tobacco ads with public service announcements, when manufacturers of these "quit smoking aids" outline the dangers of tobacco and the benefits of quitting far more times a day than the public could pay for?) Similarly, demands for suppliments ofVitamin A, iron etc. may rise after there is a comprehensive attempt to draw peoples attention to the life-saving qualities of these essential vitamins and minerals in the local foods which contain them.

Lastly but most important is the need for creativity in the design of the communication strategy. It may seem that there is a need to use every communication channel for every social message that is being pushed in developing countries, but this is not always the case. An appreciation of the communication channels unique to each message can help the communicator design a more innovative and cost effective strategy. Each issue is likely to have its own particular communication route and set of carriers. Using traditional healers in Nepal does not mean that traditional healers anywhere else should necessarily become the focus of a communicator's attention. The art is in tying the issue to a creative and influential channel, what ever that might be.

George McBean 2012