Over the past two decades, public health workers have successfully developed primary health care: basic preventive and curative services that address critical health problems and are available close to people’s homes. Primary health care includes immunizations; maternal care; education for health, hygiene and nutrition; family planning; availability of essential drugs; and first aid. The difficulty now is in making primary health care widely available and of good quality. In most countries high technology hospitals in the capital cities, and exotic, expensive drugs still dominate the expenditures for health care.
One of the advances in primary care has been the widespread dissemination of oral rehydration therapy for children’s diarrhea. Anyone who has raised children knows that certain illnesses seem inevitable: fevers, rashes and diarrhea. Children are regularly exposed to microbes in the environment. Where sanitation and hygiene are good a young child may have only a few brief bouts of diarrhea, but where food and water are frequently contaminated a child may suffer between four and eight episodes a year in the first three years of life, each lasting an average of a week — over 10 percent of its early life. UNICEF estimates that five million children die each year from diarrhea. [1]
In Egypt, diarrhea and dehydration account for about two-thirds of deaths in infants and young children — an estimated 125,000 in 1980, for instance. [2] Because diarrhea is so common — a mother of four might personally have to care for 50 episodes or more — it is too often regarded as an unavoidable part of growing up.
Diarrhea is so life-threatening because children lose body fluid and essential minerals, a condition called dehydration. Each episode leaves them weaker and less well nourished than before. It takes distressingly little diarrhea to cause life-threatening dehydration in an infant. If a child suffers with diarrhea from 30-50 days a year, that much fasting guarantees malnutrition, further damages the intestine and, in turn, prolongs future episodes.
Most bouts of diarrhea stop spontaneously and children have an excellent chance to recover if fluid and minerals are replaced. Hospitals commonly use intravenous (IV) fluids to do this, but hospitals in the Third World are often remote; the IVs are expensive, and they do nothing to help the mother prevent dehydration at the next episode.
In the early 1960s, physiologists discovered that the basic sugar, glucose, markedly increased the intestine’s ability to absorb fluids and minerals. Physicians in cholera hospitals in Dhaka and Calcutta quickly adapted the discovery to provide rehydration by mouth instead of intravenously, and they called it oral rehydration therapy (ORT). As long as a child or adult is strong enough to drink, ORT may be used: over 98 percent of cases in a community can be treated with ORT. [3]
By the mid-1970s ORT had been proved effective worldwide, even when given at home by a mother trained briefly in its use. A dehydrated infant seems able to drink as much as it needs if the fluid is offered freely and continuously. ORT also protects nutrition. Because fluid and minerals are replaced quickly, vomiting stops, and the appetite returns within hours; because glucose helps absorb fluids and minerals, the digestion and absorption of food is also easier.
Here, therefore, is an entirely appropriate technology: an effective treatment that is simple, inexpensive, can be done mostly at home, and with familiar materials. [4] It would seem ORT would be quickly and universally accepted. But more than 80 percent of diarrhea episodes in the world are not treated with ORT. Why is this?
Parents and health workers are intent on stopping diarrhea, not dehydration (which is only visible in the minority of cases). They seek to treat with so-called constipating agents (small doses of traditional concoctions or pharmaceuticals) and with powerful antibiotics — usually several at once. Unfortunately, the scientific evidence has yet to catch up to health workers and the public: that constipating drugs have no effect on watery diarrhea; that antibiotics (for complex reasons) make many cases of diarrhea worse; and neither deals with dehydration or protects nutrition.
Egypt’s Experience
Since 1952, Egypt has developed an extensive network of primary health care units readily accessible to over 95 percent of its population. Egypt also produces about 80 percent of its pharmaceuticals. The Ministry of Health in 1977 distributed UNICEF oral rehydration packets (Oralyte) to its network of primary care clinics. In 1978, a parastatal pharmaceutical company began to make ORT packets for sale through private pharmacies (like other drugs, at subsidized prices). Yet few parents and health workers were familiar with ORT, fewer used it, and many leading pediatricians remained skeptical about its efficacy (as did many Western-based pediatricians). In 1980 the health ministry intensively promoted it to families and health workers in a small cluster of rural villages in Dakahlia governorate. Compared to nearby villages, mortality of children under five years of age was reduced by 40 percent. Based on this experience, the ministry decided to mobilize its health professionals, the clinic system and mass communications to cover Egypt’s 50 million people with this life-saving, appropriate technology.
The National Control of Diarrheal Diseases Project (NCDDP) started work in late 1982, funded by grants from the US Agency for International Development. [5] Its mission was to guarantee that sufficient ORT packets are procured and distributed (sold in private pharmacies, free in government clinics); to educate health workers and families in the need for ORT and its safe use; and to research various clinical, operational and behavioral aspects of diarrhea. By the end of 1986, ORT packets were available at nearly every clinic and private pharmacy in quantities matching demand. The majority of ministry physicians and nurses providing child care had been trained in ORT, and rehydration rooms were established in 99 percent of the primary health care system. Surveys show that 80-95 percent of mothers know the signs and danger of dehydration, and virtually all know about ORT; approximately two-thirds say they have used ORT. Several dozen important studies on diarrheal disease were disseminated to the medical community. [6] Since 1982, infant mortality in Egypt has declined by 37 percent, particularly diarrhea-related mortality, which has fallen by over 60 percent. [7]
Three strategies made this program successful: first, to gain the support and collaboration of the influential medical establishment (pediatricians particularly); second, to guarantee that ORT packets would be available in sufficient quantities once the public and health workers were prepared to accept ORT; and third, to inform people about ORT and nutrition through mass communications.
A former minister of health, also an eminent professor of pediatrics, was among the firm and vocal promoters of ORT. The NCDDP extended research and training grants to Egypt’s 11 medical faculties: each faculty became involved in ORT and other diarrheal disease research (including community-based studies); medical students now learn about ORT; and the research data have been continuously useful for planning NCDDP work.
The NCDDP guaranteed the parastatal drug company that all ORT packet production would be paid for at source, to convince the company to increase production ten-fold. Television proved to be the most suitable medium to promote ORT, but advertising about health matters was a relatively new concept in Egypt. A TV campaign for family planning had been a recent, embarrassing failure. The 60-second NCDDP messages were medically accurate and tasteful, presented in colloquial language and only aired after extensive testing with urban and rural families for credibility, relevance and acceptability. The NCDDP logo, designed and revised several times, has become the most widely recognized advertising symbol. Many of the messages were presented by a popular motherly actress (Karima Mukhtar). The messages contained information rather than mere exhortation.
Future Concerns
Among the important issues the NCDDP and the Ministry of Health should consider in the next few years, the following stand out. First, physicians continue to use antibiotics inappropriately (albeit at a somewhat lower rate). Pharmacists, physicians and the drug firms have a conservative interest in not changing practices much.
Second, the project spent a lot of resources to educate families about what to do — how to recognize dehydration, how to prepare ORT at home — and unambiguously sought to increase families’ self-reliance. Yet we find mothers going to physicians and clinics as a first step more often than before. Has the project unintentionally increased families’ dependence? It is important to learn more about this.
Third, while ORT cures dehydration and with continued feeding protects nutrition, it does not affect the incidence of diarrhea. The NCDDP takes care to promote personal hygiene and prolonged breastfeeding (both measures can reduce incidence to a degree), but ultimately safe water and effective sanitation are necessary.
Fourth, appropriate technology for primary health care is not simple, though the interventions themselves (vaccines, ORT, health education) may seem so. Political will is critical to orient resources more to primary health care, less to prestigious and fantastically equipped hospitals. Foreign aid helped develop and support the NCDDP, a program which has a single focus and stands considerably apart from the main ministry bureaucracy. Will the gains of the NCDDP be sustained once the foreign grant funds are expended? The health ministry must sustain some parts of the NCDDP program, most critically the regular supply of ORT packets, continue education through mass media, and train new health personnel. While the capacity and talent are there, resources will be far fewer.
Over the next two years the NCDDP must design an orderly transition of essential functions to sustain the gains of the past seven. Assigning foreign or domestic resources is too often determined by power politics, not human needs. Earlier I mentioned, almost casually, that five million children die of diarrhea worldwide each year. If we knew them, knew their names, knew their families&rsqou; suffering, could we stand for it? Public and family health will be improved and sustained only as citizens demand it to be so, and as health workers remain their vocal and respectful advocates.
Author’s note: I appreciate the critical reading of this paper by Dr. Cynthia Myntti, and my thanks to Lisa Howard-Grabman for editorial help.
Endnotes
[1] UNICEF, The State of the World’s Children, 1987 (New York: Oxford University Press), p. 5.
[2] The figures are projections from two studies in rural villages of the Delta governorates of Dakahlia and Menoufia. See A.A. Kielmann, A.B. Mobarke, M.T. Hammamy, et al., “Control of Deaths from Diarrheal Disease in Rural Communities. I. Design of an Intervention Study and Effects on Child Mortality,” Tropical Medicine and Parasitology 36 (1985), p. 183; and B. Teckce, “Oral Rehydration Therapy: An Assessment of Mortality Effects in Rural Egypt,” Studies in Family Planning 13 (1982), p. 315.
[3] An extensive review for medical readers is: N. Hirschhorn, “The Treatment of Acute Diarrhea in Children: An Historical and Physiological Perspective,” American Journal of Clinical Nutrition 33(1980), pp. 637. Non-medical readers may consult N. Hirschhorn, “Oral Rehydration Therapy: The Program and the Promise,” in Cash, et al., eds., Child Health and Survival (London: Croom Helm, 1987).
[4] ORT is usually made from a packet containing four mineral salts and glucose in correct proportions, to mix with the requisite amount of water. It is possible to make a simpler, somewhat less effective solution at home with table salt and sugar.
[5] The NCDDP, a program within the Ministry of Health, is guided by a multi-ministerial steering committee chaired by the Minister of Health. The technical Secretariat comprises Egyptian experts — some from the public sector, some private — and between two and four US technicians contracted by the NCDDP. I worked for the NCDDP for the first two and one-half years of the project, and was a member of the original Egyptian-American planning group. The original tenure of the NCDDP was five years at $26 million (and is now extended to 1991 with an additional $10 million), with matching local resources donated by Egypt. By way of comparison, Egypt spent approximately $78 million on antidiarrheal drugs (90 percent of them clinically unnecessary) from 1980 to 1986; see the study by Dr. Amira Badr for Resources for Child Health, Washington, DC, 1987.
[6] Draft Report of the Second Joint Ministry of Health/USAID/UNICEF/WHO Review of the National Control of Diarrheal Disease Project (NCDDP) in Egypt, June 15-July 3, 1986; NCDDP Annual Report, 1986.
[7] M.K. Gabr, “The Oral Rehydration Program: The Egyptian Experience,” Third International Conference on Oral Rehydration Therapy, December 14-16, 1988, Washington, DC, US Agency for International Development. Proceedings, pp. 53-63.
