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Diarrhoea control becomes a social movement in Bangladesh

By Sabir Mustafa*

Ten-year-old Utpala Goldar is a shy little girl. When visitors come into her classroom in the rural village of Batiaghata, some 320 kilometres south of the capital of Dhaka, she peers at them suspiciously. But when asked what she knows about diarrhoea, she springs confidently to her feet, her wide eyes sparkling. "Diarrhoea causes the body to lose water, and it can kill within days if not treated properly," she says, to the delight of her teacher, Vidhyadhar Viswas, who spends a good part of his time teaching his pupils a simple remedy for diarrhoea-induced dehydration called oral rehydration therapy, or ORT for short. Mr. Viswas is one of more than 55,000 primary school teachers who have been trained in ORT in Bangladesh since 1993. He teaches his pupils that increasing a dehydrated child's liquid intake — especially using oral rehydration salts (ORS), a precisely mixed solution of sugar, salt and water — while continuing normal feeding can replace the lost fluid within hours and save the child's life. Unfortunately, Utpala's knowledge of ORT came too late for her four-year-old brother. Srinath Goldar was among an estimated 300,000 Bangladeshi children who died from diarrhoeal dehydration in 1991, the year a cyclone took 139,000 lives along the south-eastern coast. It was not the severity of the attack that killed the child, but ignorance. Like women in 93 per cent of Bangladeshi households, Utpala's mother knew how to make a solution of sugar, salt and water. But, as was the case in nearly 80 per cent of households, she did not know how to use it correctly. Diarrhoea takes a heavy toll in this country, which is criss-crossed by waterways and routinely ravaged by floods, cyclones and, recently, droughts. Each year, some 20 million children suffer an average of 3.5 episodes of diarrhoea. After acute respiratory infections, it is the second leading cause of death among children. But Mr. Viswas is confident that no one in the families of the 57 children in his tiny school will die of diarrhoea. "When teachers at primary schools convey a message to their pupils, it filters through to the mothers and reaches the remotest village in the country," he says. With primary school enrolment at 17 million and rising, that adds up to quite an impact. When the Control of Diarrhoeal Diseases Programme (CDDP) was launched in Bangladesh in 1989, it focused on treatment in health facilities. But that approach was inadequate, and in 1993 came a shift in strategy. Mobilization on an unprecedented scale was carried out, bringing schoolteachers, religious leaders, voluntary organizations, village doctors, rural groups and even local auxiliary police forces into a partnership against diarrhoea. "Diarrhoea control used to be a matter for health professionals, but it has now been turned into a social movement," says Dr. Asib Nasim, CDDP's director. Dr. Nasim likes to reel off statistics showing that the CDD programme is one of the most successful in the world. Correct use of ORT, with increased fluids and continued feeding, jumped to 45 per cent in 1994 from less than 10 per cent in 1990, and the death rate from diarrhoea is falling, dropping below 250,000 in 1995. "We are within sight of the goal of 80 per cent ORT use, a 50 per cent reduction in diarrhoea deaths and a 25 per cent reduction in diarrhoea incidence by the year 2000," Dr. Nasim says, referring to the goals set by the World Summit for Children in 1990. Dr. Nasim points out that it was in Bangladesh in the late 1960s that the ORT concept was developed and correct ORS mixes were clinically tested. The breakthrough, described by the British medical journal, The Lancet, in 1978 as "the most significant medical advance this century," made the International Centre for Diarrhoeal Diseases Research, Bangladesh (ICDDR,B) the leader in the field. It was also in Bangladesh that the most extensive public health initiative in the world took place. Beginning in 1980, field workers from the Bangladesh Rural Advancement Committee (BRAC), a national non-governmental organization, went door-to-door in rural areas, teaching girls and women how to prepare ORS at home, using half a litre of water, a pinch of salt and a handful of gur (unrefined brown sugar). By the end of 1990, BRAC had trained 12 million families in ORT. However, only a quarter of households use a home-made solution, underscoring the need to make packaged ORS available in all the 86,000 villages hat are home to three quarters of Bangladesh's 117.8 million people. An innovative partnership between the Social Marketing Company (the biggest distributors of premixed, packaged ORS in Bangladesh) and the Grameen Bank (which provides poor women with loans to set up small-scale income-producing enterprises) has opened new business opportunities for rural women while dramatically increasing access to ORS. The agreement, facilitated by UNICEF in March 1995, allows bank members — more than 2 million women in 35,000 villages — to buy the Social Marketing Company's ORSaline brand of ORS at subsidized rates and sell it at a profit. Sales of all brands of ORS packets stood at only 52 million nationwide in 1994, far short of the estimated 350 million needed annually, and there is a long way to go to build up confidence in ORT. Half a million Bangladesh Scouts are helping in this effort. In rural areas, they survey homes and register those needing ORT training. Then each Scout over the age of 11 'adopts' 10 families to teach them about ORT. Scouts below the age of 11 teach five families. As Dr. Nasim sees it, all that remains is a "big, final push to reach our goals," and that began in May 1996 with a new, 18-month communication campaign. Given the country's low levels of literacy and the scant electrification in its villages, the campaign relies on audiovisual and interpersonal communication to drive the message — 'more fluids, more often' — home to every household in the land. The aim is to boost the level of ORT use from 45 per cent to 80 per cent once and for all. That crucial change in behaviour and care, it is hoped, will finally end the cruel paradox of 250,000 children still dying from dehydration yearly in the very country where ORT was born. *Sabir Mustafa is Associate Editor of The Financial Express in Dhaka (Bangladesh).

updated: 7 May, 2015