click to enlarge photo UNICEF, India

The Promise | What needs to get done | How to get it done | The Medical profession







Sections from UNICEF 50th Anniversary (1946-1996)
Fact Sheet on Oral Rehydration Therapy (ORT) - Achievements and Challenges

The Promise

The 1990 World Summit for Children set major health and development goals for children to be achieved by the year 2000, including

• a 50 per cent reduction in deaths due to diarrhoea in children under five and
• a 25 per cent reduction in the diarrhoea incidence rate.
  
  A priority is to increase the proportion of patients receiving ORT and continued feeding to 80 per cent by the end of 1995.

Currently only 38 per cent of diarrhoeal dehydration sufferers are treated with ORT.

What needs to get done

1. Achievement and maintenance of 80 per cent ORT use and a halving of child deaths caused by diarrhoea. In 1994, 57 per cent of diarrhoea cases worldwide were treated with ORT, versus 17 per cent in 1986. Although this level of ORT use is credited with saving one million child deaths per year, more than three million children below age five continue to die annually from diarrhoeal dehydration.

2. Sustaining support for ORT use The ORT use rate tends to drop off without social mobilization efforts that continue until behavioural change is achieved and ORT becomes a family habit. For instance, Egypt launched a campaign in 1988 and within two years, 96 per cent of mothers had heard of ORT and the home usage rate was more than 50 per cent. When lack of funding put an end to social mobilization, ORT usage dropped to 34 per cent. The same happened in the Gambia, where a two-year campaign boosted usage to 64 per cent, which fell to 11 per cent a year later. Not only nations, but entire regions can thus lose ground. Eastern and Southern Africa's 60 per cent 1994 use rate actually represented a drop from the previous year's 64 per cent, and West and Central Africa's 36 per cent in 1994 represented a drop from 38 per cent in 1993. In the Americas and the Caribbean, the 1994 rate of 58 per cent was down from 65 per cent the previous year.

3. Overcoming obstacles to ORT/ORS posed by medical practitioners Because it is so simple, many doctors and other health providers are not convinced that ORT is a state-of-the-art treatment and fail to prescribe it. Especially in the industrialized world--about 500 children in the US die of diarrhoeal dehydration each year--hospitalization for intravenous therapy, which costs an average US$2,300 versus the minimal costs of a packet of ORS, is the standard procedure. Insurance companies do not reimburse for ORT, which is also a very time-consuming therapy in the hospital, since the child must be held and fed liquids for several hours.

4. Overcoming obstacles to ORT/ORS posed by drug companies The World Health Organization has determined that several types of drugs widely used in the industrialized world to treat diarrhoea are ineffective or even dangerous. These include adsorbents and antimotility drugs, both of which can stop the diarrhoea, sometimes at the risk of intestinal obstruction, but still leave a child with the risk of dehydration. Even in developing countries, manufacturers may have no financial incentive to produce such a simple product for commercial sale.

• Immodium and other antimolility drugs are not necessarily safe or effective and they do not stop diarrhoea. Actually, the diarrhoea keeps on, but they stop the movement of the intestine so that bloating can occur. Because the intestine stops squeezing, and the diarrhoea continues, that is why children (or anyone) can get dehydrated.
  
• these drugs do not rehydrate, i.e., do not replace fluids lost, nor match electrolytes lost.
  
• Adsorbents also do not stop diarrhoea. Instead they are clay-like substances with make the loose stool look more normal and formed. Again, these drugs do not replace either fluids lost nor electrolytes and fool people into thinking all is okay.

Additionally, rice-based oral electrolytes reduce fluid losses (by 20 to 30 %) and rehydrate by matching fluids lost, as is appropriate.

5. Overcoming obstacles to ORT/ORS by the general population Parents must not only be aware of the existence of ORT, but must also be taught how to use it. Because ORT stops dehydration, not the diarrhoea that causes it, many parents believe that drugs are preferable. Information and communication campaigns are necessary to dispel such misunderstandings as well as mistaken, outmoded beliefs, such as that children should not be given food or water while suffering from diarrhoea.

6. Preventing diarrhoea This can be pursued by multisectoral efforts to achieve and maintain high levels of immunization, improve access to clean water and safe sanitation, support breastfeeding and promote hygiene education.

How to get it done

• ORT should be made "a family habit" through communication, social mobilization and information;

• health providers should prescribe ORS and promote ORT for every case of diarrhoea, advise parents and give correct treatment for all types of diarrhoea;

• all health facilities - private and public - should be strengthened with skilled personnel and adequate drugs;

• preventive measures should be taken.

UNICEF, the World Health Organization, the Rockefeller Foundation, the United States Agency for International Development, Junior Chamber International, The Hunger Project and the US Centers for Disease Control and Prevention have mobilized behind these goals and placed them at the top of their agendas. The Boy Scouts have pledged their participation. The coalition of these forces promises a good beginning. But they cannot do it alone.
Here are some activities that could be carried out by individuals, non-governmental and volunteer organizations to help promote Oral Rehydration Therapy.

What decision makers can do:

• Disseminate information on the problem, and the solution, to ensure sustained political commitment and adequate resource allocation;
  
• Support the creation of a social movement to make ORT a family habit;
  
• Create an alliance of governmental and non-governmental bodies to teach correct ORT procedures to families;
  
• Ensure that families are taught the importance of the three Fs -- fluids, feeding and further help -- when children are having diarrhoeal attacks;
  
• Ensure that there is one ORS dispensing depot within walking distance for every 1,000 families;
  
• Increase the output of ORS packets from 500 million to 1 billion globally;
  
• Speak out in favour of ORT;
  
• Ask education ministers to mobilize teachers to talk about ORT in the classroom.

What communicators can do:

• point out that one of this century's most important medical breakthroughs has been largely underreported and underappreciated;
  
• report that most diarrhoea medications are useless or harmful, that only in a small number of cases are antibiotics or antimoebics the correct treatment, and that, other than ORS, medicine should be used only if prescribed by a doctor or nurse;
  
• broadcast television reports on the worldwide ORS programme to save more lives than did penicillin;
  
• assign reporters to investigate the obstacles to ORT use in their countries;
  
• use the media to promote ORT as the best scientific option for the prevention and treatment of diarrhoeal dehydration.

How to influence the medical profession:

• distribute leaflets reiterating that I.V. treatment is eight times as expensive as ORT;
  
• promote the fact recognized by modern doctors that ORT is the most scientific and cost-effective option;
  
• rally around other voices from the medical profession that endorse and reaffirm ORT.

There are doctors, nurses and pharmacists who fail to advise parents about ORT. THIS IS NOT RIGHT. All doctors, nurses and pharmacists must recommend ORS for every case of diarrhoea. When they fail to do so, it is because they have not kept up with the research about ORT or are wary of new treatments that were not taught when they were in medical school. In some countries, medical school started teaching about ORT only a few years ago.

What everybody can do:

• Convene meetings of community and government leaders to discuss specific issues related to children.
  
• Organize youth forums to discuss dehydration and the Convention on the Rights of the Child and call for its implementation.
  
• Persuade sports stars to promote ORT through the mass media, youth and sports organizations, and stadium management to display messages about the dehydration during games.
  
• Arrange encounters of leading artists, public personalities, writers and intellectuals to discuss the situation of children in the country and in the world.
  
• Organize exhibitions of photographs and art work by professional photographers and artists including children on child-related subjects.
  
• Organize peaceful marches to alert the public to such issues as dehydration, survival and child development.
  
• Urge radio stations to broadcast talk shows for youth to ask questions concerning dehydration and problems affecting children in their communities.
  
• Seek the involvement of parliamentarians in promoting ORT through round-table discussions, town meeting and meet-the-people sessions.
  
• Enlist the support of NGOs and civic and religious leaders through encounters/seminars on the well-being of children and of the importance of ORT, and ask that all places of worship dedicate services, with appropriate liturgy, music, prayers and sermons.
  
• Encourage airlines to play the ORT promotional video before the in-flight movie.
  
• Encourage transit authorities to display ORT posters on buses or subway trains, and leading merchants to display the poster in store windows.
  
• Encourage school superintendents to include an ORT course.
  
• Encourage regularly scheduled concerts and other performances to be dedicated to children, and to include messages about ORT in their printed programmes and displays.
  
• Ask radio and TV stations, and publications of all kinds, to run public services announcements and display ads about ORT and the needs of children
  
• Sell ORT T-shirts, buttons, posters, etc., to promote awareness and raise funds for local children's service and advocacy efforts.
  
• Hold an exhibition on the Rights of the Child and invite prominent community leader, the mass media and school children.
  
• Organize a road run, big walk or bike tour to raise awareness on children's issues.
  
• Raise funds to adopt a project in a developing country benefiting children.
  
• Persuade local and national libraries to highlight books on children.
  
• Organize essay-writing competitions among children and adults.
  
• Convince newspapers to carry supplements on children's issues; especially about dehydration.