The reason why a large number of children under the age of five years die of diarrhoea and pneumonia, generally in rural India and especially in Bihar, has become abundantly clear. The results of a study were published a couple of days ago in the journal JAMA Pediatrics.

Diarrhoea and pneumonia are the biggest killer diseases in children aged under five years in India. With 55 per 1,000 live births, Bihar has the highest infant mortality rate in the country. But 340 health-care providers who were studied in rural Bihar rarely practised what little they knew about treating children suffering from these two diseases.

“Vignette” interviews were conducted to assess how they would diagnose and treat children with these diseases. Later, the actual treatment offered by the health-care providers was assessed by sending “patients” pretending to suffer from the same symptoms as in the interviews.

If the providers exhibited “low levels” of knowledge about the two diseases during the interviews, it was even worse during practice. Cheap, life-saving, widely available oral rehydartion salts (ORS) with zinc supplementation is the correct treatment for diarrhoea (2013 WHO recommendation).

During the vignette interviews, a paltry 3.5 per cent of providers offered the correct treatment for diarrhoea. Another 69 per cent offered ORS, but it was in addition to other unnecessary treatments. Some even prescribed antibiotics.

Shockingly, no health care provider prescribed the correct treatment for the “patients” with diarrhoea — only ORS. It was a few shades better in the case of pneumonia where the figure stood at 13 per cent.

Again, if nearly 21 per cent of practitioners prescribed potentially harmful treatment (including antibiotics) without ORS during the interviews, an alarming 72 per cent offered dangerous cocktails that included antibiotics during practice. Antibiotics have no role to play in the treatment of diarrhoea.

In the case of pneumonia, while 12 per cent prescribed antibiotics for pneumonia during interviews, the figure went up marginally to 15 per cent during practice. Severe pneumonia requires treatment with appropriate antibiotics.

“Our ongoing studies aim to understand why providers who know they shouldn’t be prescribing antibiotics for conditions like simple diarrhoea continue to do so,” Dr. Manoj Mohanan from Duke University, North Carolina said in a release.

Besides wrong treatment, the researchers found that the health-care providers asked very few pertinent questions that would enable correct diagnosis and understanding of the severity of the diseases during practice than they did during interviews.

Even the most basic diagnostic question of frequency of stools was asked only by 46 per cent during interviews and 30 per cent during practice. Similarly, in the case of pneumonia, only 27 per cent of the providers asked about rapid breathing and 25 per cent about signs of respiratory distress during practice.

Most distressing was that during practice, 76 per cent of practitioners offered treatment despite not seeing the “sick” child with diarrhoea. It was 79 per cent in the case of pneumonia.

Eighty per cent of the providers in the study did not have a medical degree from any system of medicine — allopathy, ayurveda, homeopathy or unani medicine. While those with formal medical training did have large gaps between what they knew and what they practised, they were “significantly less likely” to prescribe harmful drugs, the study found.

Published in The Hindu on February 17, 2015