A People Centered Strategy: Attacking Diarrhea in Mozambique
By invitation of the Ministry of Health, in March 1986, David Werner visited Mozambique to help look for ways to improve its diarrhea control program.
In most poor countries, dehydration from diarrhea is a major cause of death in children. In the early 1980s, following WHO guidelines, Mozambique initiated a diarrhea control program based on oral rehydration therapy (ORT). In the coastal city of Beira, a factory was built to produce oral rehydration solution (ORS) packets for distribution through health centers to mothers of children with diarrhea. (The aluminum foil packets contain sugar and salts for making one liter of ORS). A national campaign to promote ORT was launched.
In spite of a great deal of good will, advice from international experts, and economic investment, the diarrhea control program has largely failed. Even in the city of Beira, where the packets are produced, a recent study showed that nearly one of every four children still dies of diarrhea.
South African Sponsored Terrorism in Mozambique
One reason for the failure of the ORT program is terrorism. Just as the U.S. pays the Contras to destabilize the popular government in Nicaragua, South Africa supports Bandidos to terrorize and try to overthrow the Mozambique government. Sabotage of power lines paralyzes production in the ORS factory. Attacks along highways obstruct distribution. The murder of health workers and burning of village health posts have weakened the health infrastructure. And the economic crisis, famine and chronic malnutrition aggravated by the terrorism increase the death toll from diarrhea. The Minister of Health is trying hard to sec that the people have basic health care. But he comments bitterly that “Our children will never experience their right to health until the apartheid government of South Africa falls.”
Another reason for its failure is that the ORT Program is weak in its education component both for health workers and for families. Partly because of shortages, mothers are usually given only one packet of ORS. And because ORS is promoted as “medicine” (which it is not) mothers expect it to slow down the diarrhea (which it does not) so they feel it doesn’t help, and stop using it.
Complicating the shortage of ORS packets is that they are a source of sodium bicarbonate (baking soda), which is used for baking cakes. In Maputo many nurses who have access to ORS packets supplement their income by baking and selling wedding cakes! On the black market, an ORS packet can sell for 700 meticaes (U.S. $0.30 black market value, or U.S. $14.00 legal dollar value). Since the “product approach” to ORT has failed, the Ministry of Health took interest in arguments for an “educational, home-mix approach,” put forth by David Werner in December 1985.
Just as Mozambicans face violent opposition front their South African neighbors, Central Americans are in a similar crisis. And the U.S. is the aggressor. Maintenance of health care in the region is destabilized by U.S. military actions. Lives are being lost. Please join lit the struggle to STOP U.S. INTERVENTION IN CENTRAL AMERICA.
While in Mozambique, David had a chance to visit Inhambane, a coastal town where, in spite of food shortages, the death rate from diarrhea was unexpectedly low. To find out why, he and the District Health Officer met with a group of 40 women from one of the poorest neighborhoods. They found that the women, disappointed with the ORS packets (because “it doesn’t stop the diarrhea”) continued to use their local traditional treatments of diarrhea. Local treatments include giving the children papinha (broth or thin porridge) made with rice, wheat flour, or local tubers. Mothers were using “cereal based” oral rehydration.
Although still not promoted by WHO, studies at the International Centre for Diarrhoea Research in Bangladesh, and independent studies in Nepal and elsewhere, have shown that cereal-based oral rehydration solution (CB ORS) is in many ways more effective than sugar based solutions. Sugar speeds absorption of water from the gut into the body, but a strong solution of sugar also pulls water back into the gut. Therefore sugar solutions do not reduce the diarrhea; they replace the liquid that is being lost. By contrast, cereals are made of large carbohydrate molecules that do not pull water back into the gut. As fast as it breaks down into sugar, the body absorbs it. For this reason cereal based ORS actually slows down diarrhea. Also, because absorption into the gut is not a concern with cereals, a much more concentrated solution can be used.
Therefore, CB ORT can better meet the nutritional needs of the child. Also, measurement is not critical. Thus families can use whatever cereal they have to make a safe, effective home remedy for diarrhea.
Can it be that this group of village mothers in Inhambane has found a better answer to diarrhea control than the WHO experts? And will the Ministry of Health be willing to listen to them? The answer to both questions appears to be “Yes.”
The Ministry of Health is now adopting a revolutionary plan for diarrhea control which includes the following original features:
The main focus is on education and self-reliance (rather than on ready made products and increased dependency).
Home mix cereal based ORT will be promoted, adapting recommendations to the traditional cereal of each area.
School teachers, schoolchildren and women’s organizations will be recruited as the main promoters and educators (rather than only health workers).
Participatory research. Teachers, school children and people in communities will be encouraged to experiment with different approaches to education, administration and implementation of diarrhea control, to record traditional home remedies, and to compare results and acceptance of different oral rehydration solutions.
David Werner will return to Mozambique later this year, to help plan the educational component and develop teaching materials for the country’s new diarrhea control strategy.