What some of our colleagues have already seen

The infant from one month to one year, and a room we have not been in

A good number of the people you work with trained somewhere with a different differential diagnosis.

That is the reason for this column. There are many doctors in our units who did their formative training in India, and they arrived here in Australia carrying pattern recognition that none of the rest of us has. Someone in your department has seen a hundred children with severe acute malnutrition. Someone has managed diphtheria. Someone has watched an infant with rotavirus go from playing to shocked in six hours, and knows exactly what that looks like an hour before it happens.

We tend to treat that as background rather than as expertise. It is expertise, and this column is an attempt to say so.

Before anything else

I am not from India and I have never worked there. What follows is assembled from published sources by someone standing outside the room, and I hold those who have been inside it in considerable respect.

If you are one of them and there is anything here you can correct, sharpen or add to — a figure I have misread, an emphasis that is wrong, something obvious I have missed — please tell me. I would far rather be corrected than be politely left alone.

The same age group, a different list

The mind map for this topic covers the infant from twenty-nine days to one year. Beyond the neonatal month, the leading causes of death worldwide become pneumonia, diarrhoea and malaria — things that happen at home rather than things present at birth. That much is the same everywhere. What differs is the scale, and the company those diagnoses keep.

PneumoniaRoughly 15% of Indian under-five deaths, on the order of 140,000 a year. Pulse oximetry at first contact matters more than any imaging.
Diarrhoeal diseaseRotavirus alone accounted for around 37% of paediatric gastroenteritis hospitalisations in Indian sentinel surveillance before vaccination.
Severe acute malnutritionCounted for the first time in 2024 as a direct cause: over 100,000 deaths globally in the one-to-fifty-nine-month group — and more than half the world's severely malnourished children are in South Asia, with India's prevalence (very low weight relative to height) of around 19% the highest of any country. The true toll is far larger still, because malnutrition is usually recorded as the background rather than the cause: the child dies of the pneumonia that a well-nourished child would have survived.
TuberculosisIn an unwell infant, a differential that exists in India and is routinely forgotten here.
Vaccine-preventable diseaseDiphtheria, pertussis, measles — diagnoses most Australian trainees have read about and never met.

The clinical point, not the geography

Malnutrition changes the physiology, not merely the context. A severely malnourished infant in shock tolerates fluid differently, has a different cardiac reserve, and carries a mortality from fluid-refractory shock that would be unrecognisable in a well-nourished child. Colleagues who trained where this is common have judgement about it that cannot be got from a guideline.

And the same is true in reverse: they arrive here and have to learn a system with retrieval services, unlimited pathology and a consultant on the phone at three in the morning. Expertise moves in both directions. It is worth asking which way it is moving in your unit this week.

And the part nobody tells you

The story most often told about Indian child health is a story of burden. The more interesting story is what has happened to it.

79%

fall in under-five mortality, 1990 to 2024 — from 127 per thousand to 27

2014

certified polio-free, having had the largest burden on earth

2015

maternal and neonatal tetanus eliminated

Behind those numbers is an immunisation programme that now covers twelve diseases, an indigenous rotavirus vaccine developed and manufactured in India, and a delivery network built on ASHA and Anganwadi workers — community health workers, overwhelmingly women, reaching villages no clinic reaches. Full immunisation coverage rose from 62% to 76% between the fourth and fifth national family health surveys. The campaign that drove it is called Mission Indradhanush: indradhanush means rainbow, for the range of vaccines and the range of children.

A child born in India today is roughly five times more likely to reach their fifth birthday than one born in 1990. That is one of the largest improvements in human survival achieved anywhere, in any period, and most of us in Australian intensive care could not name a single element of how it was done.

Two things

For those who have lived or worked in India

What did you see there that you have not seen here — and what would you want the rest of us to know about it?

This column only works if the people who have been in that room are the ones writing it. Tell me what we are missing. I would rather publish your account than my summary of it.

Tell me what you saw

For anyone at all

What should this column be called?

The India Room is a placeholder, and I chose it precisely because I did not want to pick a language. The other columns are le coin français, l'angolo italiano, el rincón español — each a corner, each in one national language. India has twenty-two, and choosing one of them is not a neutral act. So the name should come from the people it belongs to rather than from me. Send suggestions, in any language, with what they mean.

Suggest a name

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