What can be done to prevent such needless and entirely avoidable injuries? Must we as it were “sin and then pray for grace to abound”? Worldwide experience suggests a multidisciplinary approach is most effective. Health care personnel cannot do it all; the problem is much bigger. Several approaches may be helpful:

PUBLIC EDUCATION

Increasing public awareness of this problem is an obvious antidote. Parents and caretakers should be aware of the risks posed by caustics and their ingestion. Several caustic agents are common in homes including the caustic soda for soap-making, household detergents, dishwasher solutions, drain cleaners and the like. These should be stored in their proper containers and kept out of reach of children and unsuspecting adults. The practice of decanting such solutions into commonly available bottles only increases the likelihood of the case of mistaken identity and should be utterly discouraged. The philosophy of “NEVER TOUCH OR TASTE WITHOUT ASKING” must be embraced by all. Some countries have adopted one week in every year to focus on Poison Prevention Education for the citizens and have obtained gratifying results.

APPROPRIATE LEGISLATION

Appropriate legislation protects all citizens through the rule of law. It is amazing how freely one may obtain such caustic agents. In this country, caustic soda is sold on the open market as one would sell salt or sugar. Interestingly, caustic soda is not infrequently mistaken for sugar. One of our patients on returning home from school hungrily took several spoonfuls of this “sugar” and added it to his ‘garri’, dissolved the mixture in water and helped himself to what turned out to be “a meal of fire”. The mother had bought the powder in the market and was yet to dissolve it for soap-making. Laws that restrict the availability of such substances are appropriate. It should be clearly defined what category of people may obtain such agents and what precautionary measures the buyers must exercise to qualify for the right of purchase.

PACKAGING

Proper packaging facilitates identification. With appropriate warning symbols attached, would-be victims may be alerted to the possibility of injury. Certainly, the sale of caustic agents in a packageless manner should be condemned. It should be required of producers to apply proper and safe packaging techniques to reduce the likelihood of accidental ingestion. Another useful technique is the control of the concentration of the agent in the package. Low concentrations should be required of producers of caustics so that in the event of accidental ingestion, the injury would be less than otherwise. This again goes to show how dangerous it is to dispense the agent in solid form to the unsuspecting public - very high concentrations are likely to be involved with accidental ingestions and injuries will be correspondingly severe.

REINFORCEMENTS

The last proposed measure is the use of economic incentives (tax breaks, exemptions, discounts) for desired behavior by manufacturers and consumers and penalties (mainly fines) for undesirable acts. Manufacturers can be afforded tax relief for promoting safer features on their products, and unsafe products can be made less affordable. Fines levied through failure to comply with safety legislation can also serve as an incentive to safer behavior.

These measures may help reduce the number of innocent children and unsuspecting adults who are subjected needlessly to such risks and have to go through complicated surgical procedures to salvage an otherwise normal swallowing mechanism.

Ama had her first operation which entailed placing a feeding tube into the stomach; the other end of this tube was exteriorized. This enabled administration of a fluid diet as well as water into her stomach. It built her up nutritionally and prepared her for the second and more extensive operation twelve weeks later. She literally blossomed after the first operation as her starving little body took in the supply of nutrients. She was back in three months for the second operation. In this operation, part of her large bowel was removed and used to fashion a new oesophagus. One end of this new gullet was joined to her stomach while the other end was tunneled to reach her throat. The newly constructed gullet required a week of rest to heal but it was all joy afterwards when young Ama swallowed normally again. In all, it had been a five month ordeal of inability to eat or drink, of denial of the pleasure of taste despite the stimulating aromas in the home environment. It had been the endurance of two major operations in the space of three months in a two year old and the attendant financial implications. As mother and child walked out of the hospital overjoyed, health care personnel shared their joy but at the same time wondered “Need this be?”