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A simple solution
MOST of the tiny patients confined to the children’s ward at the
International Centre for Diarrhoeal Disease Research (ICDDR) in Dhaka,
Bagladesh, are weak, malnourished and dehydrated, they have suffered attack
after attack of diarrhea and, in some cases, are clinging to life.
Five-month-old Sohag who is lying on green plastic sheeting in a bed four
times her size, had suffered diarrhea for seven days before she was admitted
at the International Centre for Diarrhea and Research (ICDDR). Her weight
had dropped to 2.75 kg, just over one-third of that expected for her age and
she now seems to be little more than a distended stomach, bulging head and
collection of scrawny limbs. According to the chart at the foot of her bed,
she may also have pnemonia and sepsis. But at the root of her problem is
chronic diarrhea, a daily killer of 5,000 young children in the developing
world and the cause of one-third of child deaths in Bangladesh. Her
15-year-old mother, Jhuanana, had never heard of diarrhea before she was
advised to take Sohag to ICDDR’s. hospital. There, the baby received saline
solution through a vein in her arm, and a rice-based solution through a tube
in her nose.
Weak as she is, patients like Sohag who make it to a hospital are the lucky
ones. Most of them are treated and released within a few days, as her doctor
expected Sohag would be. But many children never reach a treatment center
and die from dehydration as they lose critical body fluids faster than they
can be replaced. Like Jharana, their family members don’t know how to
prepare a life-saving remedy that can be assembled for just a few pennies: a
large pinch of salt and a fistful of sugar dissolved in a jug of clean
water, the simplest recipe for oral rehydration solution. “To save the life
of a person with diarrhea is probably the cheapest health intervention you
can think of,” says David Sack, an American doctor who is the ICDDR’s
executive director.
Cheap; but nothing like as commonly available as it should be. Oral
rehydration has saved the lives of more than 40 million children since it
was first put to the test during a cholera outbreak among refugees on
India’s border with Bangladesh in 1971. But decades later, it remains
grossly underused. The result, according to the World Health Organization (WHo):
3 million people a year still die from diarrheal complications, including
1.9 million children under 5, or 17% of the estimated 11 million deaths in
that age group. These deaths are largely preventable and unnecessary. “We
have the tools to really reduce deaths”, says Olivier Fontaine, a diarrheal
disease expert at the WHO in Geneva, Switzerland. “The cost of this
intervention is minimal. Yet we can’t get it to every child that needs it”
Why not? Because crowded cities and remote areas of poor countries often
don’t have adequate health facilities nearby; because many parents of young
children never learn how to make oral rehydration solution at home; because
sachets of the powdered mix require packaging, storage and distribution to
those who need them; because oral rebydration does not initially reduce a
child’s stool output, leading some parents to conclude that it doesn’t work,
and give up. Because—perhaps above all—our sense of global health priorities
is uncomfortably skewed. While diarrhea is a major killer in developing
countries, in the rich world it is usually no more than an irritant. So
developed nations channel health-care funds into areas perceived as
presenting greater risks. Antiviral drugs are purchased and vaccines are
ordered to guard against the potential threat from avian influenza instead
of getting packages of rehydration solution costing just 6$ a liter to those
at risk of dying from diarrhea elsewhere. But far more children die from
diarrhea every day than have ever died from avian flu.
Diseases that have high profiles and vocal activists - such as AIDS,
tuberculosis and malaria - attract far more interest and money from big
donors and governments, based partly on the mistaken belief that they kill
the most children. Celebrities don’t host concerts to fight diarrhea. Of 29
child-health specialists at major international development agencies
surveyed by the Rotavirus Vaccine Program—a charity based in Seattle,
Washington—40% named AIDS, tuberculosis and malaria as the three greatest
child- killers. In reality; the top three are pneumonia, diarrhea and
malaria. “this problem isn’t getting the attention it deserves”, says mdee
Varavithya, a doctor who has treated diarrheal diseases for nearly 40 years
in Thailand. That needs to change.
Most cases of diarrhea can be traced to food or water tainted by 100 or so
intestinal bugs, most commonly rotavirus, E. coli shigella, campylobacter
and salmonella. Thumb sucking doesn’t help; it can lead to what doctors call
fecal-oral contamination. “Toddlers will always pickup things and put them
into their mouths and, if you dont have a clean environment, that can lead
to diarrhea”, says Therese Dooley, until recently a UNICEF project officer
in Ethiopia. Infection triggers a cascade of events that can cause diarrhea,
if left untreated, to escalate from an unpleasant experience to a
life-threatening condition. Normally, 50-75% of the human body is water. The
small intestine serves as its key pumping station, absorbing water and
nutrients through its walls. There, nutrient-rich fluids enter the
bloodstream, which transports them to other parts of the body. But when the
intestine detects a pathogen in its midst it stops soaking up fluids and
disgorges its contents in a watery rush of stools. The consequence is what
we know as dehydration.
Oral rehydration treatment can reverse dehydration in more than 90% of
patients, even in cases of the severe diarrhea caused by bugs like rotavirus
and cholera. When the solution reaches the small intestine, the sugar is
moved from the hollow part of the intestine into its mucosal lining through
the villi, small fringer like projections on the intestinal wall. “it’s like
having a chemical needle in the intestinal tract;’ says William Greenough, a
professor of medicine at Johns Hopkins School of Medicine in Baltimore,
Maryland, and a former director of ICDDR. Sugar’s chemical properties allow
salt to be absorbed more efficiently. The salt then promotes the absorption
of water into the capillaries within the intestinal wall, which carry the
water and electrolytes to other parts of the body and restore fluid balance.
The connection between diarrhea and fluid loss was first noted in 1830 by a
surgeon working for the British East India company in Calcutta. But interest
in treating diarrhea didn’t gain ground until devastating cholera epidemics
swept the subcontinent in the middle of the last century. Fluid loss from
cholera-related diarrhea occurs so rapidly that its victims can die within
four to eight hours or, as lore has it, before they can dig their own
graves. Cholera is still a leading cause of diarrhea in Bangladesh’s
southern Ganges River basin. Vaccines preventing cholera have never been
completely effective or long-lasting, so when ICDDR was established as the
Cholera Research Laboratory in 1960, its mission was to evaluate such
treatments. By the late 1960s, the facility had begun experimenting with
oral rehydration and, within a few years, fatalities among its diarrhea
patients had dropped from 50% to zero. Across the Bangladeshi delta, oral
rehydration was also gaining ground at the Johns Hopkins Center for Medical
Research and ‘Training in Calcutta. Teams at both centers knew they had an
effective treatment—but they faced resistance from a profession that
dismissed such a basic remedy as inferior to costlier IV saline fluids.
The opportunity to prove oral rehydration’s worth came in the form of a
disaster. When Bangladesh’s war for independence from Pakistan broke out in
1971, 9 million refugees poured into India, bringing cholera with them.
Dilip Mahalanabis, an Indian doctor who had participated in the oral
rehydration trials at the Johns Hopkins Center in Calcutta, began using IV
saline treatment at a border camp, but within weeks his supplies were
exhausted. Amid awful scenes in which people walked for days only to die,
Mahalanabis and his team drew on their experiences in Calcutta. They formed
an assembly line to weigh out correct proportions of rehydration ingredients
in plastic bags, sealed the bags with an iron, and mixed the powder with
water so patients’ friends and relatives could collect it in mugs. “We
converted the library at Johns Hopkins into a factory,” Mahalanabis, now 79,
recalls. “We brought in drums with side-taps, filled them up and sent them
to the field. We were essentially using people to experiment on. But we were
pushed to the wall. We had no choice”. Using lay people to administer the
treatment while health workers replenished supplies was controversial.
Doctors had long assumed that, in untrained hands, rehydration solution
might be prepared in the wrong concentration and kill more patients than it
saved.
Mahalanabis’ gamble paid off. The fatality rate among the patients in the
camp fell to 3% from 30%, and to less than 1% when IV fluids were
administered to the most severely ill. Still, skepticism about the
effectiveness of oral rehydration continued. Several journals refused to
publish Mahalanabis paper about the outbreak . But Dhiman Barua, then head
of WHO’s bacterial diseases unit in Geneva, Switzerland and a survivor of
the massive 1932 Cholera epidemic in Bangladash’s southern port city of
Chittagong, had visited Mahalanabis camp. He was converted and pushed orala
rehydration through all the U.N. health agencies. WHO rolled out its
diarheal diseases control programme in 1978.
The simplicity and power of this tool gave it its own momentum”, Mahalanabis
says. Power indeed: the initiative cut total worldwide diarrhea deaths from
about 5 million in 1980 to 3 million today.
In Bangladesh alone, child mortality fell from 35% to 6% over 20 years. But
far too many people are still dying from preventable diarrheal diseases.
Today, according to UNICEF, diarrhea still claims the lives of 36,000 young
Bangladeshi children a year Infants like Sohag would perish if they didn’t
live near a hospital because they were born to parents unfamiliar with oral
rehydration. For the third time in 12 days, 6-month-old Ullash has been
admitted to the ICDDR’s children’s ward; just one of 325 patients admitted
within the last 24 hours. The boy weighs only 69% of the expected weight for
his age and is malnourished. He has a high fever, a cough and persistent
diarrhea. His parents, Jurin and Nazdin, educated Dhaka residents, wait
anxiously as he receives intraenous fluids. “We don’t understand where this
is coming from”, says Nazdin. But Sack, the center’s executive director
knours. Malnutrition and diarrhea go hand-in-hand, and in Bangladesh both
are so widespread that not even middle-class children can escape their
self-perpetuating cycle. “If you have P a child that is malnourished and who
then loses more weight through diarrhea, and tries to make it up, but never
makes it up because he is weak and has another episode of diarrhea, then it
doesn’t matter how well-off the parents are”, he says. “That is a child who
is on the road to death:
ICDDR spends $20 million a year treating up to 150,000 patients, its budget
financed mostly by grants from the government, international aid agencies
and charities. At an avenge cost of $5 a day for each patient, the center
stretches that money a long way. When the monsoon season begins, the
hospital erects giant tents in its parking lot to cope with the extra
patients. But the sucess of the hospital in Dhaka has not been replicated
elsewhere.
In Africa, the fight against diarrhea is hampered by the lack of clean water
and the infrastructure necessary to ensure public health. In countries like
Ethiopia, only 40% of people have access to safe water, and fewer than 1 in
3 has regular access to safe sanitation, which at a minimum means a pit
latrine. Most Ethiopians don’t make the connection between the way they
dispose of human waste and their family’s health; instead, they believe that
“diseases are transmitted by the will of God”, says Worku Fertahun, bead of
health for the Banja district in the country’s north.
As a consequence, the average Ethiopian child suffers five to 12 episodes of
diarrhea a year. Based on studies by the country’s government and the World
Bank, and by the Ethiopian Ministry of Health, between 50,000 and 112,000
Ethiopian children under 5 die from diarrhea every year. So for the past
three years, UNICEF, the government, churches and NGOs have led a campaign
to teach Ethiopians the basic principles of hygiene, the importance of
washing their hands and how to build their own toilets. The government has
also trained health extension workers, mostly women, who can then teach
other villagers about sanitation.
Birhanu Worku, who cultivates half a hectare or so of potatoes and barley,
was one of the first in Banja to build a pit latrine three years ago. It’s a
simple affair: a hole in the ground, 1 m across and 3 m deep, covered with a
concrete slab and surrounded by mud walls, a thatched roof and a bamboo
door. Outside the toilet is a plastic watering can, which Worku has
jerry-rigged to dispense a trickle of water for flushing. His neighbors, he
says, “came and asked me why I built it and how it worked ... I told them
what I had learned and they listened and then went home and built their own
toilets”. More than 25,000 households joined the latrine-building boom in
just three years. The number of people with access to a latrine in Banja
district rose to 86% today from 3% in 2001. Toilets became status symbols.
“Some people are building latrines nicer than their houses”. says Gabeyew
Tarekegn, who lives in a nearby village. Worku says that his children have
been sick less often since the family began using the latrine and washing
their hands afterward.
At the Gafft Primary School, amid the eucalyptus trees of Adet, up to 40% of
the students used to suffer regular diarrhea attacks, especially after the
rainy season when sewage seeps into water supplies. “If the students get
sick”, says teacher Tesfaye Birhanu, “they can’t learn their lessons and
think freely”. Until recently, the four toilets shared by Gafft’s 1,266
pupils were fittly, and girls like Genet Solomon avoided using them.
“Before, I would get sick once a month”, says Solomon, 12. Then the school
built three simple pit latrines in cinder-block cubicles. A sanitation club
began encouraging students to wash their hands after using the toilet and
before meals, a simple way of reducing the risk of diarrheal illnesses. Now,
fewer than 20% of the students fall ill. Solomon has been sick once in the
past six months. “Hand washing is such a simple thing, but it can have a
major impact on a child’s health,” says UNICEF Dooley.
Simple remedies such as oral rehydration and pit latrines don’t make the
world’s headlines. Yet recurrent bouts of diarrhea not only disrupt a
child’s schooling, but also retard physical development as vital nutrients
are continually flushed out of the body. One ray of hope: preliminary
studies suggest that zinc supplements protect the intestine’s lining and
significantly reduce the duration of diarrhea episodes as well as the risk
of recurrence. At ICDDR’s field research center southeast of Dhaka, children
who were given a 10-day course of zinc tablets after developing diarrhea had
30% fewer relapses, and 20% fewer developed pneumonia, reducing overall
deaths by 50%. The cost of a course of zinc: about 25. With funding from the
Bill and Melinda Gates Foundation and support from the U.S. Agency for
International Development, an ICDDR program now aims to provide zinc tablets
to every child under 5 in Bangladesh.
Vaccines also hold promise for preventing some types of diarrhea. The most
common cause of diarrhea in children is rotavirus, which leads to severe,
watery diarrhea. Researchers believe it infects almost every child in the
world by age 5 and kills 600,000 of them a year in poor countries. (Children
who contract the virus in rich countries, by contrast, usually recover
quickly because they are treated aggressively.) The first vaccine approved
for prevention of rotavirus, Wyeth’s Rotashield, was taken off the market in
1999 after several children who received it developed a rare but serious
complication in which the bowel folds in on itself. Preliminary studies
suggest this problem has been overcome by Merck’s Ro taTeq, which was
approved by regulators in Europe and the U.S. earlier this year, and
GlaxoSmith-Kline’s Rotarix, approved in Europe in February. Like other
vaccines, they work by provoking the development of antibodies that protect
against future infection. Both are given orally. Clinical trials of both
drugs have been encouraging. Evan Simpson, a public-health specialist at the
Seattle-based Rotavirus Vaccine Program, says the new vaccines have the
potential to reduce deaths from rotavirus-related diarrhea to 200,000 a
year. As with oral rehydration treatment and zinc supplements, though,
distribution remains a hurdle. “The rotavirus vaccine is a potential silver
bullet,” Simpson says, “but you’ve still got to get it to them”,
The cost of a vaccine—about $60 a dose in countries such as ‘Canada, France
and South Korea—makes distribution difficult in poor parts of the world.
Beatrice De Vos, Glaxo’s director of worldwide medical affairs, says her
company has adopted a”south first” strategy of pricing to provide steep
discounts on Rotarix for poorer countries if they have a system for
vaccinating all young children. thatrheal disease experts say Glaxo is
selling its vaccine for as liffle as $7 a dose in Brazil. “For the poorest
developing countries that’s still unaffordable, but with greater use and
greater manufacturing, that price will go down,” says Roger I. Glass,
director of the U.S. National Institutes of Health’s Fogarty International
Center and former chief of the viral gastroenteritis unit at the CDC in
Atlanta, Georgia.
One dollar is about the price that Thai doctor Wandee would like to pay for
the rotavirus vaccine. Rotavirus is the leading cause of diarrhea in Thai
children today. In the 40 years since Wandee began championing oral
rehydration at the Ramathibodi Hospital in Bangkok, deaths from diarrhea
have dropped to 1 in 10,00(1 diarrhea patients from 1 in 1,000, she says.
Thailand has fob lowed a cost-effective approach by organizing education and
training workshops on oral rehydration for pediatricians, hospital staff,
pharmacists and—most importantly—health workers and volunteers in tiny,
remote villages. The country has also developed a system to track outbreaks
so that doctors and scienfists can work to prevent repeats. That’s in
contrast to most of Africa and to neighboring Burma, Cambodia and Laos,
which Wandee says resist public counts of diarrhea cases lest they put off
foreign investors and tourists. “If the governments do their job and allow
NCO5 to reach down to the community level;’ Wandee says, “we could save more
people. We could prevent 2 million deaths a year if we could reach out to
all the villages!’
Saving 2 million lives a year, you might think, is a cause with which
politicians and movie stars would fall over themselves to be associated. But
tackling diarrhea has never had the high profile of other public-health
crises. There’s much to do; though experts know what interventions can
reduce needless deaths, getting them in place is not always easy. There are
thousands of villages in places such as Bangladesh’s muddy delta and the dry
northern expanses of Ethiopia that still lack the infrastructure, education
and methods of treatment thatwould protect their children’s lives. To be
sure, there is some good news; a recent report by UNICEF found that global
access to safe drinking water rose from 1990 to 2004. But 1.1 billion people
still don’t have clean water; 2.6 billion lack a basic toilet. “That’s an
infrastructure problem and a development problem that we have not been able
to deal with;’ says Greenough of Johns Hopkins. If the world wants to avoid
the needless deaths of yet more children, it’s time that we did.
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SUNDAY, NOVEMBER 19 2006