Troubled waters

Parents of children who attend Be Van Dan School still remember the rainy November afternoon, four years ago, when Nguyen Quoc Dai attempted to walk home alone. The school lies in a busy district of Da Nang, Vietnam, that residents say is acutely affected by seasonal flooding. Even during the dry season, neighborhood ditches, canals, ponds, and the nearby South China Sea pose safety hazards for children. The 6-year-old Dai started by turning left out of the school's iron gates and walking beside its mustard-yellow concrete wall. Cars, trucks, and motorbikes whizzed by as he approached the banks of the Gio Bay Canal. Neighborhood kids like to fish and frolic there. "He wanted to play," recalls school principal Nguyen The Quyet. But the little boy couldn't swim, and when he fell into the canal, he drowned.

Afterward, says Quyet, "everyone knew we needed to do something." Many school parents started to forbid their children from walking home unsupervised. City authorities built a bridge over the canal to replace a dirt crossing. But Quyet says he knew those measures wouldn't address the roots of much larger problems. Some experts describe drowning as a global public health threat just beginning to attract attention as the death toll from illnesses like diarrhea and malaria declines. "As we've cut down those mountains, the hill of drowning has become visible," says Shams El Arifeen, who directs the Centre for Child and Adolescent Health at the International Centre for Diarrhoeal Disease Research, Bangladesh. Yet compared with researchers working on major threats to public health such as HIV/AIDS, infectious diseases, and road traffic fatalities, those who work on drowning receive comparatively little recognition or funding from governments and international donors. "Drowning is not seen as a problem by the health care system," says Arifeen. "But if you talk to families, while it may not be No. 1 on their lists [of health concerns] it's still high up there."

The International Life Saving Federation (ILS), created in 1993 to help reduce water-related injuries and fatalities worldwide, said in its 2011 year-end message that "drowning remains a leading cause of death among children and the leading single cause of child mortality (age 1-17) in low-resource, densely populated Asian nations." But a search for reliable, up-to-date figures can be frustrating. The most recent World Health Organization (WHO) data are from 2004, when according to WHO almost 400,000 people drowned worldwide, nearly half of them under 20 years old. But ILS argues that, because many drownings are not officially reported to hospitals and the WHO's global drowning estimate doesn't account for natural disasters or transportation accidents, the figure is likely closer to 1 million annual deaths. WHO admits that its published estimates are low. "Kids don't drown in hospitals. They drown in canals, lakes, rivers, and oceans," says David Meddings, a WHO scientist specializing in child injury prevention. "Very frequently when a child or adult drowns, there's very little in the way of [mortality] registration data."

In recent years, UNICEF and WHO have published preliminary findings as officials from low- and middle-income countries—whose populations are more susceptible to drowning than those in high-income countries—have begun to incorporate drowning-reduction programs into larger risk planning strategies. Today, as some nonprofits and governments attempt to prevent drowning through swimming education, researchers are investigating the causes of drowning and brainstorming new—albeit largely untested—interventions.

A participant in this research is the Johns Hopkins International Injury Research Unit. Its director, Adnan A. Hyder, SPH '93, '98 (PhD), is an associate professor of international health who turned his attention to drowning after earning his doctorate from the Bloomberg School of Public Health. Hyder conducts research in Bangladesh, where national data suggest drownings account for up to a quarter of deaths among children between the ages of 1 and 4. He has documented the country's drowning burden and devised inexpensive household interventions, such as playpens and door barriers, that he hopes will be adopted in communities there and beyond. It is a formidable mission in a nation where the average worker earns about $550 per year and cultural norms can contradict what Americans would consider commonsense safety measures.

Steve Beerman, president of the Belgium-based ILS, says that Hyder and other Johns Hopkins researchers have produced research on child drowning that has influenced advocates and policymakers in countries across South and Southeast Asia. Hyder isn't the only leader in the field, Beerman adds, but his work has raised public awareness of a largely unreported epidemic. According to Meddings of WHO, studies on drowning by Hyder and other Johns Hopkins researchers have helped experts in the field better understand what drowning risk factors look like on the ground in South Asia: "Relatively speaking, there are very few people doing research in this field, so the work that people at Hopkins are doing is extremely important."

Hyder, who is 45, grew up in Karachi, Pakistan, and traces his lifelong interest in public health to the awareness of social inequality he developed as a medical student at Karachi's Aga Khan University. Some of his course work included research in urban slums, where the people he met battled horrific diseases near hospitals that they could not access. "I was coming from a middle-class family, and while I had been aware that these communities existed, I had never worked with or spent any time with them," he recalls. "Everything struck me as horribly wrong, and there arose in me a sense of the tremendous social injustice that was occurring in our country."

Hyder moved to Baltimore in 1992 for graduate study at the Bloomberg School. He joined the school's faculty in 1998, and much of his research over the last 13 years has focused on public health problems in South Asia. His overarching goal is to prevent injuries in the developing world, and his research interests are as wide-ranging as the countries he has visited. Over the years he has studied emergency medical care in Pakistan, traffic law enforcement in Uganda, and injury patterns among Afghan refugees. Drowning is one of the obscurer fields he has tackled. "I am the type of person that gets interested in the types of things other people are not interested in," Hyder says. Ten years ago he wasn't aware of any other scientists researching drowning in the developing world, but the more he looked into the issue in Bangladesh, the more he grew convinced that his research would bear fruit.

He and his colleagues began by combing existing population surveys. Hyder says these showed that about one in five young child deaths in a rural study site were attributable to drowning. Twenty years ago, the number might have been one in 10, Hyder explains; the new data suggested that drowning deaths relative to total deaths in the area were rising because deaths from diarrhea and infectious diseases were decreasing. Their first paper, "Death from Drowning: Defining a New Challenge for Child Survival in Bangladesh," was published in 2003 by the International Journal of Injury Control and Safety Promotion. According to Hyder, it effectively announced to the international public health community: "Whoa, folks, wait a minute. What's happening is you're saving children from one cause [of death] only to lose them to another."

Hyder's next step was investigating the causes of child drowning, using Bangladesh as a case study. This was a challenge. Social norms and indigenous belief systems made it tricky to decipher how and why children were drowning. Some parents blamed drowning on what they mysteriously called an "evil eye." Hyder and a team of researchers joined forces with Lauren S. Blum and Rasheda Khan, anthropologists from the Centre for Child and Adolescent Health at the International Centre for Diarrhoeal Disease Research in Bangladesh, to dig beneath the language that people in local communities used to discuss drownings. The researchers discovered that residents attributed drownings to either a water goddess that preys on children, or "evil spirits" that trick mothers into forgetting about them. In some cases, a parent would refuse to save a drowning child out of a mistaken belief that doing so would kill the child. In other cases, a mother would rescue a child from the water but, rather than call for help, would massage the child with garlic and mustard oil. Friends and relatives often blamed a child's mother for the death. "My husband still says the child died because of me," one grieving mother told the researchers. "I do not see why I would be blamed. Did I kill her willingly? Do I have lots of children to spare?"

Hyder and his colleagues began brainstorming interventions that might prevent very young children from drowning in those communities. That presented another challenge. Although many children in Bangladesh and other poor countries in Asia live near unguarded canals and ditches, it was inconceivable that their parents would embrace—much less be able to pay for—safety measures such as protective fences that typically protect young kids from water hazards in the United States and other developed countries. So he worked with his colleagues to develop two inexpensive interventions—a playpen and a door barrier—that they hope will be compatible with local customs but also prevent young children from wandering off while moms are preparing a midday meal or doing household chores. He is also working on a wireless bracelet designed to trip an alarm system if a child falls into water.

Because of funding constraints, however, Hyder is stuck at the theoretical phase of his research. Until he receives a grant to conduct a large pilot study of community-based drowning interventions in Bangladesh, he says, he won't have enough evidence to prove whether the interventions actually work. For example: Would those nifty-sounding wireless bracelets he is helping design actually save children who fall into water? Or would they simply slip off wet, skinny wrists? Lack of funding has always hampered his research on drowning. Even a grant from the U.S. Agency for International Development that provided him with about $50,000 annually from 2004 to 2008 was roughly two to four times less than what he says other researchers typically receive to study infectious diseases. It isn't that drowning is more important than other public health issues, Hyder is quick to insist, but that drowning research doesn't receive enough funding relative to its tragic global impact. "Governments and donors want to be told about things they can do to help people," he explains. "We're stuck: We think some of these tools are pretty cool, but I have no scientific evidence to tell you they work. Therefore, why would you give me money?"

Other players in drowning prevention take a different approach to the problem. The Alliance for Safe Children (TASC) and the Royal Life Saving Society-Australia, for example, have partnered with UNICEF and in-country institutions to launch SwimSafe, an ambitious effort to prevent primary school-age kids from drowning. Ross Cox, TASC's senior operations officer, says the program has trained 150,000 children in survival swimming in Bangladesh since 2006 and 15,000 in Vietnam since 2009, and that no drownings have been reported among graduates.

SwimSafe's Vietnam work focuses on Da Nang, where since 2009 it has constructed 11 portable pools at local schools and offered free swimming lessons on an annual budget of $250,000. One of the pools sits beside Be Van Dan School, a stone's throw from the canal where 6-year-old Nguyen Quoc Dai drowned on that rainy day in November 2007. On a recent afternoon at the school, a group of 10- and 11-year-olds splashed in the pool as two 20-something Vietnamese SwimSafe instructors in wetsuits and swim caps blew whistles and demonstrated proper techniques.

Nguyen Thi Phuong Loan, whose daughter Huynh Phuong Hoang My was paddling an orange kickboard across the portable pool, said she is grateful for the SwimSafe program. "Swimming is a healthy activity," Loan said over the sounds of splashing and laughing. "And if my daughter ever gets into trouble in the water, she'll be able to rescue herself."

Across town at the Furama Resort Danang, Kat Waterhouse, a volunteer funded by the Australian government, is training lifeguards to prevent drownings in the white-capped waters off Non Nuoc Beach. At least 150 school-age kids have also learned to swim at the upscale resort since a "Nippers" swim-training course kicked off last summer. Duncan MacLean, the resort's general manager, says his long-term goal is making the beach the safest in Vietnam and a model for others along the country's long coastline. "We don't want to teach all Vietnamese to become Olympic swimmers, but we want to teach as many people as we can the basics of water safety," MacLean said on a recent afternoon at the resort.

Although efforts to teach swimming and educate lifeguards sound promising, drowning experts have not yet determined whether either is an effective intervention. A 2008 United Nations report on child injury says vaguely that "concern has been voiced" that teaching kids to swim en masse could lead some of them to become "overconfident" and thus lead to increased rates of child drowning. (The source is a 1999 paper in the Journal of the American Medical Association.) The U.N. report, which Hyder co-edited, adds that the most effective way to prevent drowning is to eliminate potential safety hazards, such as holes in the ground that can fill up with rainwater during storms.

Hyder notes that while he thinks teaching kids to swim is a good idea in general, he has not seen scientific evidence proving that swim lessons reduce rates of drowning. "Many NGOs want to jump right into action, and I appreciate that," he says. "I'm not against action. I'm just against action without appropriate evidence." But Justin Scarr, chief operating officer for Royal Life Saving, says the role of Hyder and other academics is to provide data on the drowning epidemic that inspires others to conduct community-based interventions. "Adnan's work is making a call for action, and at the other end you have community development-type NGOs that are actually in the field responding" to the drowning epidemic, says Scarr, whose organization partnered with the U.S.-based TASC to launch SwimSafe. TASC's work, Scarr adds, "has been significant from an Asian perspective, but given that they're not an institution like Hopkins, they haven't taken the time to publish their research through academic channels." SwimSafe's website says the program was inspired by a three-year study in Bangladesh that proved "children who learn survival swimming are protected from drowning." Asked for a copy of the study, Scarr told Johns Hopkins Magazine in December that it was in press and couldn't be released.

Hyder says he is looking forward to reading future studies by TASC and other organizations that evaluate swimming interventions as a potential drowning-prevention tool for school-age kids. In the meantime, he says, he is searching for new funding so he can collect his own evidence about home-based intervention tools for very young kids in Bangladesh. "The field of drowning prevention right now is at a level where there are a few players genuinely interested in making a change," Hyder says. "I don't think any one of them has the golden key. All of them are really at the same stage—waiting to see how they can move forward."

Advocates and researchers alike are waiting for governments to take more action. Although several countries, including Bangladesh, Vietnam, China, and Thailand, have publicly acknowledged the problem, Hyder says, they haven't yet "shown their teeth" by implementing large-scale, coordinated reforms. But pressure is mounting. Last May, policymakers and drowning experts gathered in Da Nang for the World Conference on Drowning Prevention and issued the first-ever list of suggestions to governments, NGOs, and the lifesaving community around creating a "world free from drowning." And from July to October, record floods swamping parts of Southeast Asia accounted for nearly 800 reported deaths—about a quarter of them children— and called attention to a killer that usually strikes one household at a time.

"An issue that is so devastating to such a significant degree requires more attention," says Beerman of the International Life Saving Federation. "We have a moral obligation to act. We need resources for more research work but also more application of what we already know."