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Then in 1971, a team led by Dr. Dilip Mahalanabis of Calcutta's
Johns Hopkins Center for Medical Research accomplished a near miracle among victims of
advanced cholera in a camp for refugees from the war in East Pakistan (now Bangladesh). Only 3.6 per cent of the 3,700 patients treated with ORS died. The Indian
team had proved that, taken orally, ORS is transported with great speed through the walls
and membranes of the small intestine. The high glucose content of ORS replaced the fluids,
salts, electrolytes and potassium flushed out by diarrhoea.
OBSTACLES TO ORT USE
It is an erroneous belief that because I.V. treatment costs more, it is
better. A study among babies treated for severe diarrhoea at Chicago Children's Memorial
Hospital showed that I.V. costs an average of US$2,299.50 per infant, compared to
US$272.78 for each baby treated exclusively with ORT. The study did not show that intravenous rehydration was better. Yet
every year, 600 children in the United States, who could have been saved with ORT and
correct management, die from diarrhoeal dehydration. "In spite of our knowledge, an enormous gap still exists -
25 years after its discovery - between the availability of ORS and its actual
application." - UNICEF Executive Director James P. Grant The US, where 16.5 million children suffer from diarrhoea every year,
spends US$1 billion a year on I.V. rehydration for 300,000 children hospitalized for
diarrhoeal episodes. Dr. Julius Goepp of Johns Hopkins University, who is among
medical practitioners trying to promote ORT in the US, often quotes physicians as saying:
"I like ORT but I don't get reimbursed for giving it. So I use I.V. treatment." ORT also requires hospitals to change their attitude towards parents.
Hospitals prefer I.V. treatment, because ORT entails holding the child and feeding the
child fluids for several hours, something mothers may cherish but hospital staff do not.
I.V. does not require hands-on attention from busy professionals. Another obstacle is resistance to change. ORT has received seals of
approval from pediatric academies and societies around the world, but many hospitals and
physicians are reluctant to prescribe ORT. Although ORT is 'low-cost', it is not 'no-cost'
--- and adequate resources are not made available for nationwide programmes. Also, families need to gain the knowledge and ability to act
promptly and correctly. Every family should be taught that even a child with the worst kind of
diarrhoea, including cholera, can be saved by giving plenty of fluids, continuing
feeding and knowing when to seek further help.
Diarrhoea: Cause and effect
Diarrhoea is caused by bacteria or viruses. The key factors are unclean
water, dirty hands at mealtime and spoilt food. Children who are malnourished suffer much
more; in turn, diarrhoea weakens children and makes them more malnourished. There is
always some degree of dehydration, and, most often, the draining of too much fluid from
the body is the cause of death. Diarrhoea can be prevented through exclusive breast-feeding, improved
weaning practices, measles immunization, use of latrines, washing hands (the baby's as
well), keeping water and food clean, washing with soap before touching food and by
sanitary disposal of stools.
THE CHALLENGE
Only 38% of diarrhoeal dehydration sufferers are treated with ORT. The
1990 World Summit for Children set 27 major health and development goals for children to
be achieved by the year 2000, including a 50 % reduction in deaths due to diarrhoea in
children under five and a 25% reduction in the diarrhoea incidence rate. A priority is to
increase the proportion of patients receiving ORT and continued feeding to 80% by end of
1995. To achieve these goals:
- 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 there forces promises a good beginning. But they cannot do
it alone.
WHAT IS AT STAKE
Oral rehydration therapy(ORT) saves the lives of more than a million
children a year , but much remains to be done to make it accepted universally as the
standard treatment and prevention of choice for all types of diarrhoea. This year, 3 million babies will die of dehydration caused by diarrhoea
-- that is 57,000 a week, 8,000 a day, six every minute. A sustained effort to make ORT
the standard in every corner of the world can thus potentially save some 19 million
children before the end of the decade -- 7.4 million in Africa and the Middle East, 10
million in Asia and 1.6 million in the Americas.
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. A firm proponent of ORT, Dr. David Bratt, a pediatrician at the General
Hospital in Port of Spain (Trinidad and Tobago), says: "The major problem today is
the attitude of most of the general practitioners. Invariably, these doctors over
prescribe antibiotics, antidiarrhoeals, anti-emetics and antispasmodics for diarrhoea.
Invariably, no information on rehydration is given."
BRINGING ORT HOME TO THE WORLD
PERU
In 1991, more than a quarter of m million Peruvians came down with acute diarrhoea during
a cholera epidemic that swept across the nation. Less than 1 per cent died because 3
million packets of ORS were distributed and administered by a group of community workers
with knowledge of ORT who trained others on the spot. MEXICO
President Carlos Salinas de Gortari has launched a national programme to make ORT a family
habit and to implement several measures to control diarrhoeal diseases. Already 86 per
cent of mothers know how to prepare and administer ORT correctly. Through their 'white
flag' project, thousands of mothers and fathers are taught life skills, including ORT.
When everyone in a community is educated, a white flag is hoisted. EGYPT
The Government fully supports the programme, and four out of five mothers use ORT at home.
ORT is used in more than half of all cases of infants and young children suffering from
diarrhoea. The National Control of Diarrhoeal Disease Project, chaired by the Minister of
Health and aided by distinguished public health academics, is one of the most successful
in the world, credited with saving at least 1 million children's lives. BANGLADESH
Bangladesh is now geared up to implement a nationwide programme. A tremendous change is
promised by a powerful partnership between NGOs --- Boy Scouts, Girl Guides, The Hunger
Project, Junior Chamber International and the Bangladesh Rural Advancement Committee
(BRAC)-- - combined with measures to strengthen health facilities. SOUTH ASIA
All countries have started programmes to bring ORT to individual homes, and to administer
it through health facilities. LATIN AMERICA
Almost all countries have drawn up plans for promotion of ORT and control of diarrhoeal
diseases. A second phase will bring basic sanitary improvements and clean water all
municipalities. AFRICA
Most countries are in various stages of bringing ORT into every home. Plans are under way
for nationwide programmes. February 1994
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