Nun Chini Pani—a Culturally-Sensitive, Visually-Creative ...

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Nun Chini Pani—a Culturally-Sensitive, Visually-Creative Commu-nication Campaign to Reduce Diarrhoeal Deaths in Nepal1

Arvind Singhal* and Yuki Azaad Tomar

International Journal of Communication and Social Research Vol. 4&5, No.1&2: 2016-2017

Introduction

One of the great achievements ofhumankind in the past 50 years is theprecipitous global decline in the mortalityof children below 5 years of age(UNICEF/WHO, 2013). In 1960, almost1 in five children died of preventablecauses; by 2015, the number had droppedto 1 in 24. In the past 50 years, countriessuch as Brazil and China have reducedtheir child mortality rates over 10-fold, andeven in countries of Sub-Saharan Africa,child mortality has declined from 1 in 4

children 50 years ago, to less than 1 in 10in 2015 (Roser, 2016).

While many factors explain this declinein childhood mortality, includingimproved standards of living, rise ineducational levels, and increased accessto immunization and health care, asignificant contributor of this decline is thewidespread use of oral rehydration therapy(ORT) to combat diarrhea. In 1980, nearlyfive million children under 5 years diedeach year from diarrhea; in 2000, this

* Corresponding authors’ email: [email protected]

Which medicine has saved more lives than any other and can be made byanyone in their kitchen....[or] a shantytown hut—as long as they haveaccess to clean water? The answer is: eight teaspoons of sugar, half ateaspoon of salt and one litre of water. Mix. Drink....It requires nospecialized equipment; uses ingredients that are ubiquitous and have along shelf life; has few side effects; and can be made up in any quantity—the perfect medicine.”

- British journalist, Jeremy Laurance2

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figure had dropped to 1.8 million. By2015, despite 2.5 billion bouts of diarrheaamong children under the age of five,annual diarrhoeal deaths were at about1million (UNICEF/WHO 2009; 2013).ORT has helped save an estimated 50million children’s lives from diarrhea overthe past five decades (Fontaine, Garner,& Bhan, 2007), and it is no surprise thatthe medical journal Lancet called it“potentially the most important medicaladvance of this [the 20th] century.”3

In the present article, we describe andanalyze the experience of one country—Nepal—in launching a culturally-sensitive, visually- creative socialmobilization and behavior changecommunication campaign to promote theadoption of ORT (ORT includes the useof oral rehydration solution [ORS] alongwith continued breastfeeding during thetime of diarrhea). While the Nepali ORTcampaign—called nun chini pani (“saltsugar water”)—occurred some 30 yearsago, and is widely regarded as a“breakthrough” communication campaign(Singhal, 2008), its culturally-sensitive,visually-creative elements have not beenpreviously documented or published inone place. A few reports, documentingsome facet or the other of this campaign,can perhaps be dug up in dusty archivesof global development agencies, but theproject is largely forgotten, if not totallyerased from data vaults and memorybanks. So, the modest and humblepurpose here is (1) to bring nun chini panialive again for students, scholars, teachers,and practitioners of communication andsocial change, (2) to especially highlight

its innovations in cultural sensitivity andvisual literacy, and (3) to distill some keylessons learned about effectivecommunication campaigns.

While we did not play any direct rolein the programmatic or evaluationcomponents of nun chini pani when it wasimplemented in Nepal in the mid-1980s,we learned about this life-saving campaignduring 2007-2008 when author Singhalwas asked to conduct a historical globalanalysis of UNICEF’s “breakthrough”efforts in communication for change (seeSinghal, 2008). Data-sources for thispiece included an analysis of (1) archivalreports made available by UNICEF andWorldview International Foundation(WIF), the two agencies that collaboratedon this campaign, (2) personal interviewscarried out by both of us over a two-weekfield visit in Nepal in January 2008 withsome two dozen key officials, artistes, andpractitioners involved in nun chini pani,and (3) photo documentation of keycampaign events, artifacts, and outcomes.While the narrative that follows benefittedgreatly from two iterative rounds of crosschecking and feedback from keyprincipals involved in the campaign andfrom UNICEF colleagues interested in itsdocumentation, the opinions expressedhere do not reflect the opinions of theconcerned agencies.

Nun Chini Pani: The Life-SavingElixir

Among the predominantly Hindupopulation of Nepal, the epic poem,Ramayana, is an integral part of peoples’cultural and religious ethos. In the poem,

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Nun Chini Pani—a Culturally-Sensitive... Arvind Singhal and Yuki Azaad Tomar

The opening sequence of the ORT video inNepal shows Hanuman bringing backSanjeevani.

Between 1984 and 1987, in the countryof Nepal, nestled among the Himalayanmountain peaks in South Asia, anotherkind of Sanjeevani was being promotedto prevent the needless deaths of 45,000young children dying each year fromdiarrhoeal diseases. The life-restoringSanjeevani, in this case, was a homemadesolution of nun chini pani (“salt sugarwater”), technically referred to as oralrehydration solution (ORS).

Partnering with WorldviewInternational Foundation (WIF), UNICEFplayed a leading role in planning,

Launch of the Nun Chini Pani Campaign with aposter and banner-decked elephant roaming thestreets of Kathmandu

Reframing Traditional Healers:Hindrance to Ally

When the nun chini pani campaign gotunderway in 1984, the mass mediainfrastructure in Nepal was severelylimited: no national television, few radiosets, and a highly illiterate population(fewer than 20% of women could read).The dispersed and remote location of somany of Nepaleses’, and a paucity oftrained medical personnel in rural areas,meant that the 400,000 Dhamis andJankris (traditional healers) were highlysought after by families of sick children,

designing, and implementing this nunchini pani initiative in Nepal, whichhelped reduce the number of annualdiarrhoeal deaths from 45,000 children inthe mid-1980s to 30,000 by mid-1995. Bythat time, 96% of all Nepalese householdswere aware of the oral rehydrationsolution, a remarkable accomplishment ina country where the reach of mass media(at least up until the early 1990s) was fairlylimited.

when Lakshmana, the brother of LordRama, is wounded, Rama’s discipleHanuman flies to the Himalayas to obtainthe medicinal herb Sanjeevani (literally“one that restores life”). Unable to identifythe Sanjeevani among other herbs,Hanuman wrests the entire mountain fromthe land and carries it back to saveLakshmana’s life.

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especially during the monsoon season,when the cases of diarrhoea peaked. Whenplotted on a graph, this seasonal variationin the frequency of diarrhoea cases lookedlike a Himalayan mountain peak.

The traditional healers, highlyrespected by the ordinary citizens ofNepal, insisted on withholding liquidsfrom the children suffering fromdiarrhoea, advice that wascounterproductive to restoration of health,and often fatal. The logic was nothing goesin, nothing comes out. Research revealedthat, for four months of the year, anestimated 400,000 well-intentionedtraditional healers were giving the wrongadvice eight to 12 times a day to Nepalesefamilies4.

Diarrhoeal deaths in Nepal peaked in the monsoonseason

Dhamis and Jankris, influential traditionalhealers in Nepal

The campaign’s biggest challenge wasto educate the traditional healers in Nepal,without alienating or upsetting them, toprovide the correct information to familiesof sick children, while concurrentlypromoting the use of ORT. Echoing theattitude of most Western medical experts,the professional medical community inKathmandu perceived these healers asdangerous quacks. However, thecampaign team grasped the importance ofenlisting the 400,000 Dhamis and Jankrisas allies in this campaign. Their influenceamong the common people, especiallyabout health issues, was enormous; thechallenge was how to tap it and then “ride”it.

One of the campaign goals was toincrease the use of oral rehydrationtherapy by promoting a homemadesolution of nun chini pani. A palmful ofsugar, plus a three-finger pinch of salt inthree standardized tea-glasses(omnipresent in Nepal) of water wasagreed to be a reasonable rehydrationmixture. The key would be to creativelyconvey the information on how to mix thehome solution correctly, have people doso, and then for them to teach others whodid not know: an ambitious exercise in acountry with high rates of illiteracy,mountainous terrain, and highly dispersedpopulation.

How to train and reach the 400,000traditional healers? Who would havecredibility and influence over them? Theanswer: Nepali Gurkha soldiers, retiringfrom British Gurkha Regiments, returningto Nepal to live in their home villages.


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Why not train them in the preparation ofnun chini pani before they returned to theirvillages? They could in turn gather thelocal traditional healers together and teachthem how to mix the homemade solution.Given the influence, respect andcredibility wielded by the Gurkha soldiers,and given their close ties with their homevillages, this opinion leaders influencestrategy for the traditional healers, as wellas the common people, could push ORTto the country’s remotest corners. Over aperiod of three years, with the approval ofthe British and Nepalese GurkhaRegiments, retiring Gurkha soldiers weretrained in the intricacies of mixing nunchini pani, becoming the vectors throughwhich the traditional healers and ordinarycitizens were trained in remote locations.

Retired Nepali Gurkha soldiers in Nepalundergoing training in how to mix nun chinipani

Visual Literacy Innovations

A remarkable aspect of Nun Chini Paniwas the various innovations in the practiceof visual literacy, given the non-literateenvironment of the remote and ruralpopulation. For instance, among the

Gurkha’s arsenal was a special memorycard, designed and developed for them touse and to distribute to traditional healers.It visually demonstrated how to make thehome solution. Over 250,000 of these nunchini pani memory cards were printed onheavy stock paper with an image of Durga,the goddess worshipped by traditionalhealers. The image of the deity ensuredthat the card was not thrown away. WhenI interviewed Raju Dahal of WorldviewInternational Foundation (he wasintimately involved in the design andimplementation of this campaign) inJanuary 2008, he noted that these cardscould still be found in people’s homes,some 24 years after the campaign waslaunched.

The front and back of the sturdy cards with animage of the deity Durga and instructions onhow to mix nun chini pani

For instance, some 250,000 meters ofthe traditional Dhaka pattern cloth wasprinted (using wooden blocks) with visualinstructions on how to mix ORS. This nunchini pani cloth was used to makeumbrellas for health workers and Gurkhas,curtains in health posts, shirts for young


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mothers and rickshaw pullers (so that thepassengers sitting behind could learnabout the home solution), and also smallvests so that children visiting a clinicwould be given a vest with the instructionfor ORS across the very stomach that wassuffering.

The nun chini pani clothes with instructions onmixing ORS

Another innovative experiment invisual literacy involved creation of posterswith life size illustrations of both theamounts of sugar and salt as well as thesize of the glass (the standard tea glass inNepal) required for the ORS mix. Peoplecould measure the size of the glasses tobe used against the poster. Research andstrategic thinking even went into thechoice of colors for the posters: orange toappeal to the relatively more traditional,older people; and blue to appeal to theyounger, more urban audience.

A Poster with Life Size Illustrations of the Ingre-dients Needed for the Home Solution

The designs of almost all nun chini panimaterials (posters, cloths, cards, stickersand the like) benefited from the results ofa study of “visual literacy” that was carriedout by UNICEF in Nepal under theleadership of Ana Haaland in the 1970s;later, this knowledge base was expandedand further developed under the leadershipof George McBean, ProgrammeCommunication Chief in UNICEF’s NepalOffice in the mid-1980s. Their work andexperience emphasized that people’svisual awareness skills improvedsignificantly after they were taught howto “read” pictures. Such knowledge, oncediscovered and operationalized, led to theproduction of more appropriate and highquality project materials, especially fornon-literate audiences.5 An interestingfinding of these visual literacy


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experiments in Nepal was the discoveryof the powerful impact of animation onaudiences.6 7 Animated images that couldhelp explain how things worked,especially through comic characters,captured audience interest. This workedwell in depicting sensitive topics such assanitation, abuse and sex.

Amplifying Through Media andSocial Mobilization8

The mass media component of nunchini pani was launched on Radio Nepalwith a theme song performed by NupurBhattacharya, a popular singer, andaccompanied by several Public ServiceAdvertisement (PSA)s9 about how to mixthe home solution.10 The theme song wasalso visualized (put onto video) andbroadcast on national television (justgetting underway in the KathmanduValley). The three-minute video was titledSanjeevani, and the opening sequence (asdepicted in a previous photo) included amythological image of Hanuman returningto save Lakshmana’s life. In apredominantly Hindu country, such epicimages can evoke primordial resonanceabout the life-restoring qualities of nunchini pani.

While the nun chini pani mass mediacampaign was blanketing the Himalayanairwaves, and retiring Gurkhas promotedthe home solution both with traditionalhealers as well as the families of sickchildren, mobile ORT teams (comprisingfour to five people) were recruited, trainedand sent from district to district todemonstrate how to mix the homesolution. These demonstration sessions,

lasting for an average of two hours, invitedaudience members to the stage to preparethe ORT solution themselves, thusaffording numerous opportunities forrepeating and reinforcing the correct wayof mixing the home solution, as alsoadministering it. In closing, the mobileteam members would encourage thosewho attended to share their know-howwith others, and sent them home withposters and with the Durga memory cards.Some 2,000 public demonstrations, eachinvolving direct contact with 200 to 300people, were carried out far and wide inNepal. With Nepal’s population estimatedat about 16 to 17 million in the mid-1980s,an estimated 3 to 4 per cent of thepopulation directly encountered a mobileteam demonstration. In addition, a cadreof several hundred boy scouts and girlguides in Nepal (out of the 40,000 scoutsand guides) conducted hundreds of ORTdemonstrations, especially in schools,playgrounds, and other locations whereyoung people gathered.

A demonstration on how to mix ORS in a remotearea of Nepal


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Further, some 32 women’sorganizations were mobilized all acrossNepal to promote the nun chini paniinitiative, including the Lions Club, Ex-Army Wives Association as well as thePolice Women’s Association. Further, theDirector General of Nepal’s postal systemwrote a personal letter to all 26,000 mailcarriers in Nepal to spread the word onthe home solution. Given these mail-carriers covered practically all householdsin Nepal, in terms of their involvementgreatly, aided the campaign’s mission.

Two of Nepal’s most famouscomedians – Madan Krishna and HariBansha Acharya (known as the Ma-HaJodi, or “pair”) – adopted the campaignand put nun chini pani instructions on theiraudio tapes, in their live performances, ontheir radio programmes, and on videos oftheir puppet performances.11 Theirpopularity helped get the ORT messagesinto countless households. When thepresent author-Singhal, met them inKathmandu in January 2008, the modestMa-Ha Jodi conceded that where healthworkers might have difficulty gainingentrance, the routines of the two belovedcomedians were welcomed into Nepalihomes.

Hari Bansha (Left) and Madan Krishna (Right)doing a comedy routine for television.

Life-Saving OutcomesSeveral mid-term and summative

assessments12 of the nun chini panicampaign (1984 to 1987) were carried outin Nepal. The key findings: some 85 percent of the people in Nepal had heardabout nun chini pani, of which three outof five people heard it on the radio, andsome 20 per cent from their neighbors.One in three families said they actuallytried to make the home solution, and onein three could accurately describe the rightmix of ingredients. An estimated 40,000lives of children under the age of five weresaved during the three years the nun chinipani campaign ran (Singhal, 2008), andits ongoing ripples year after year havesaved an estimated half-a-million Nepalichildren in the past three decades. Whilethe use of ORT has waxed and waned inNepal in the past several decades, in 2015,ORT was still the first line of defense fromdiarrhea in 40 percent of the cases(UNICEF/WHO, 2009; 2013).

The studies also pointed out that thehome solution was not guaranteed to bemixed properly by everyone who wastaught, and the recall of the mixingtechnique diminished with the passage oftime. Given the dangers of preparing andadministering an “incorrectly” mixedsolution (for example, if one mistakenlyreversed the amount of salt and sugar, the“life-saving” potion could prove fatal), itwas useful for UNICEF and other localhealth partners to expand the range ofoptions offered to the caregivers of a childsuffering from diarrhoea. Additional


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possibilities included continuedbreastfeeding during diarrhoea episodes,using pre-mixed ORS packets, and usingsubstitutes such as salted rice water orsweetened tea with salt, available inalmost all Nepali homes.

ReferencesFontaine, O., Garner, P., Bhan, M.K. (2007). Oral rehydration therapy: the simple solution for

saving lives. British Medical Journal, 334, doi: http://dx.doi.org/10.1136/bmj.39044.725949.94

Roser, M. (2016). ‘Child Mortality’. Published online at OurWorldInData.org. Retrieved from:https://ourworldindata.org/child-mortality/ [Online Resource]

Singhal, A. (2008, unpublished). Where practice has led theory: UNICEF’s contributions to thefield of communication for development. New York: UNICEF, C4D Unit.

UNICEF/WHO, (2009). Diarrhoea: Why children are still dying and what can be done. Retrievedfrom http://www.unicef.org/media/files/Final_Diarrhoea_Report_ October_2009_final.pdf

UNICEF/WHO, (2013). Ending preventable child deaths from pneumonia and diarrhea by 2025.Retrieved from http://apps.who.int/iris/bitstream/10665/79200/1/ 9789241505239_eng.pdf

ConclusionOur purpose was to bring back to life

the culturally-sensitive and visually-creative elements of the Nepali life-savingnun chini pani campaign tocommunication students, scholars, andpractitioners.

What key lessons were learned from thenun chini pani campaign?

1. Large-scale social mobilizationinitiatives benefit from a strategicintegration of mass media andinterpersonal channels, aided by a trainednetwork of ground-based opinion leaderswho command influence, respect andcredibility in their peer group. The retired

Gurkha soldiers in Nepal fulfilled this roleadmirably.

2. A culturally-grounded understandingof local barriers and resistances (e.g. theprevailing beliefs of traditional healers),as well as of potential allies and “entrypoints” (e.g. Gurkha soldiers) can begained through research and dialogue.Such findings were crucial in crafting lowcost, high impact solutions in Nepal.

3. Crafting messages in local, cultural,and religious contexts of understandingamplifies audience resonance andreceptivity. The use of Durga memorycards and the “epic” alignment betweennun chini pani and Sanjeevani was criticalto harness and ride the existingsensibilities and undercurrents.

4. For communicating with non-literatepopulations, the know-how about visualliteracy techniques must be systematicallyshared and harnessed to its full advantage.Such was done remarkably in the nun chinipani campaign.

Endnotes1 This case draws upon Singhal (2008, unpublished), reports and pamphlets about Nun Chini Pani

provided to us by Worldview International Foundation (WIF) and UNICEF Country office in


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Kathmandu, and a non-dated manuscript provided by author George McBean titled ‘A Solution WorthRemembering.’ Innovative Communications and Oral Rehydration Therapy in Nepal. McBeanscanned and shared this manuscript with author Singhal via email on August 29, 2007 and alsoprovided several campaign photos from his archives, including a few that are used here. It would notbe possible to reconstruct the salient elements of this campaign without the back-and-forth withMcBean (formerly UNICEF’s Programme Communication Chief in Nepal during the time of thiscampaign) and the personal courtesy extended by Raju Dahal of WIF in Kathmandu, who also dugup various materials on the campaign from dusty data-vaults, and allowed us to photograph keyaspects of the campaign, including a screenshot of the ORT video with Hanuman bringing backSanjeevani, the life-size poster on ORT, and the nun chini pani clothing (all embedded in the case).We are grateful to the Ma-Ha comedy team of Madan Krishna and Hari Bansha Acharya, who gavegenerously of their time in Kathmandu. Our deepest gratitude to the (former) programmecommunication staff in Nepal’s UNICEF regional and country offices including Dutta Tray Roy,Sharad Ranjit, and Deepa Pokharel, for their insights. Gratitude also to the then UNICEF C4Dcolleagues in New York—Rina Gill, Robert D. Cohen, and Ketan Chitnis—who inspired and supportedthis inquiry in the first place.

2 See Jeremy Laurance’s Top Ten list on life-saving medical breakthroughs. http://www.independent.co.uk/life-style/health-and-families/health-news/the-greatest-eureka-moments-419452.html

3 See the Lancet quote here: http://scienceheroes.com/index.php?option=comcontent&view=article&id=65&Itemid=113

4 Gleaned from George McBean undated manuscript.5 George McBean reinforced this point in his email memo of March 16, 2008: The quality of the

communication materials that were produced in Nepal for this campaign was very high and, I believe,were a large part of the success of the project. Even in today’s world they stand out as good examples.

6 Especially on non- and pre-literate (people who belong to a culture where there is no written languagein their environment) audiences, although animations are also popular among literate populations.

7 Gleaned from George McBean undated manuscript.8 Data for this section (on demonstrations and social mobilization) were gleaned from pamphlets and

reports provided by the Worldview International Foundation.9 The PSAs included a jingle of the theme song to breed familiarity with campaign materials.10 Part of the radio message’s appeal was an invitation to the audience to help join in this campaign and

spread the knowledge of ORS to save children’s lives. Many of the best ideas for the promotion ofnun chini pani (which we detail later) came from the public themselves.

11 Personal interview with the Ma-Ha Jodi in Kathmandu on January 13, 2008.12 Data for this section were gleaned from pamphlets and reports provided by the Worldview International

Foundation.

Authors’ biography

Arvind Singhal, Ph.D. is the Samuel Shirley and Edna Holt Marston Endowed Professor ofCommunication at The University of Texas at El Paso and also appointed as Professor 2, Faculty ofBusiness Administration, Hedmark University of Applied Sciences, Norway.

Yuki Azaad Tomar is an Assistant Professor of Development Communication & Extension atInstitute of Home Economics, University of Delhi.


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