Oral Rehydration Therapy (ORT): A Simple Life-Saving Technology—or Another Way of Exploiting the Poor?
After respiratory infections, diarrhea is the world’s biggest killer of children, draining the life out of 13 million youngsters each year. Diarrhea is especially dangerous to malnourished children, of whom there are more in the world today than ever before. The immediate cause of death from diarrhea is usually dehydration, or loss of fluids. Timely and effective fluid replacement (rehydration) can often prevent death. Some fluids are more effective than others. There has been much debate about which fluids are best to promote.
In the recent past the medical profession believed that the best way to rehydrate children with severe diarrhea was to use IV (intravenous) fluids. But such treatment is costly and requires skilled personnel. This makes the technology unavailable to millions of poor families. Then, in the 1960s during a massive cholera epidemic in Bangladesh, doctors lacked the trained personnel required to provide IV fluids to more than a small fraction to those who needed it; they tried giving by mouth the same sugar-and-salt solution used in the IVS. With this oral solution the death rate from cholera fell from over 30% to under 1%.
In 1978 the British Medical Journal Lancet declared Oral Rehydration Therapy as the most important medical breakthrough of the century.
The Evolution of Oral Reyhydration Therapy (ORT) at Project Piaxtla: Three Stories
Like many technologies, Oral Rehydration Therapy (ORT) can be either beneficial or counterproductive for disadvantaged people, depending on how it is introduced and who controls it.
The village health team of Project Piaxtla from the time it began 30 years ago-has learned this lesson the hard way, by trial and error. It has experienced both the life-saving potential of ORT and the risks of promoting it in a disempowering way. And the local health workers have made an effort to learn from their mistakes.
The following two true stories, taken from the early years of Project Piaxtla, illustrate both the potential and the pitfalls of promoting Oral Rehydration Therapy.
Story #1: The Needle and the Spoon
Back in 1974, a young French doctor, Mark Lallemont, volunteered for a few weeks at Project Piaxtla. Shortly before his return to Paris he told me (David Werner) the following story:
“Did I tell you how your village health worker, Martín Reyes, saved the life of a baby after I had failed?” Mark asked me.
“No,” I answered. “How?”
“It was a Sunday morning during the rainy season,” began the young doctor, “and unbelievably hot. I was alone in the Clínica de Ajoya when this young couple comes in with a sick baby, about a year old. They tell me his name is Filiberto and he’s had diarrhea and vomiting for 3 days. I saw the poor kid was dangerously dehydrated. His eyes were sunk and dry, and his skin was wrinkled like a prune. He hadn’t urinated since the day before.
“I told them the baby needed IV solution right away. But the worried father said he thought the baby was too weak to resist it. ‘It’s the one chance to save your baby’s life!’ I pleaded. At last the father gave in.
The mother held the whimpering baby while I tried to get a needle into a vein. You know how hard it is with a baby … and with the dehydration his veins were partly collapsed. I tried one vein after another. I was really sweating it. So were the parents. They kept begging me to stop hurting him, and just give up. His mother started to cry, which made me even more nervous. I realized that if I didn’t get liquid into the baby quickly, he would die. And for all I knew, his parents would blame me.”
The French doctor smiled nervously. “I tell you, I was really scared! In a big city hospital it’s different. You don’t have the parents as your assistants. You’re more insulated: you’ve got nurses, consultants, anesthesiologists and tons of equipment; you can avoid getting so close … You know what I mean?
“I decided the only way to get into a vein was to do a cutdown.” [make a small cut in the baby’s skin to expose the vein] Mark continued. “I explained to the parents what I was going to do and why. But his mother suddenly cried ‘NO! My baby has suffered enough!’ I tried to explain, but she snatched up her baby and ran out of the clinic. The father, before following her out, turned to me and said, ‘Thanks in any case. I guess we brought him too late.’ ‘Wait!’ I protested, “The baby can be saved!' … But they were on their way out the door.”
The young doctor made a gesture of frustration and despair. “I felt angry and foolish. I thought of getting a court order, until I recalled where I was. Minutes later Martín came into the clinic with another sick person. When I told him what had just happened, he asked me to attend to the person, and ran out to look for the parents and dehydrated baby.
“Well,” Mark sighed, “It was the next morning before Martín next showed up. His eyes were red and he looked weary. ‘Is the baby dead yet?’ I asked.
“‘Not at all!’ said Martín with a big smile. ‘He still has runny shit, but he looks a whole lot better and has begun to take food. He is pissing often and sheds tears when he cries.’
“I couldn’t believe it. ‘You did a cutdown?’ I asked.
“Martín shook his head. ‘No, we spoon fed him liquid.’
“‘But didn’t he just vomit it up?’ I asked. ‘Oh, yes,’ Martín replied sleepily. ‘But each time he vomited we gave him more. We gave him a spoonful of water with sugar and a little salt in it every 3 or 4 minutes all afternoon and all night long.’
“‘You stayed with the family all night long?’
“‘All night. I learned a long time ago that when it’s a matter of life and death, and when a family is learning new skills, it’s safer if the health worker stays with them to make sure they keep it up. Most families traditionally give fluids to babies with diarrhea, but many simply don’t give enough. It takes a lot of reinforcement.'”
The French doctor paused and spread wide his hands expressively. “Voila! Little Filiberto survived … thanks to Martín and his patience and understanding.” He smiled at me. “So you see, a village health worker has taught this doctor something I never learned in medical school. In fact, he has taught me a lot.
Story #2: The Piaxtla Wonder Drug
Through its own mistakes, the Piaxtla health team has learned the harm that can come from medicalizing and mystifying Oral Rehydration Therapy. In its early years, the team made great efforts to get village families to accept ORT. To convince mothers to use it, they made some of the same mistakes UNICEF, WHO and international health campaigns have made and still make. They mystified and medicalized what is potentially a simple home solution. It happened like this:
When Piaxtla health workers began to promote ORT in the 1960s, mothers were reluctant to simply give their sick child a home-made drink made of common household ingredients (sugar, salt, and baking soda). They wanted real medicine. So the team tried to fool them. They packaged measured quantities of sugar, salt, and soda in little plastic bags, and added a pinch of red Kool-Aid to make it look medicinal. They promoted this mix as the Piaxtla Wonder Drug.
For the most part, acceptance was good. But soon the health team realized its deadly mistake. During the rainy season when more children get diarrhea, flooding rivers and slippery trails blocked access to health posts. Children died for lack of a simple ORT drink mothers could have made in their own homes. By leading people to believe they needed a “wonder drug,” health workers deprived them of that life-saving knowledge. In terms of its scientific formulation, their Wonder Drug was safe and effective. But within the geographic and social context in which they worked, it was dangerous. The dependency it promoted cost chil-dren’s lives. An alternative was needed that would place ORT technology in people’s hands.
Making the shift was not easy. But fortunately the program was still small and flexible. It had no big investment, economically or politically, in its misconceived “wonder drug.” Its aim was simply to help disadvantaged people meet their needs. So the health workers gathered courage and openly admitted to the villagers that their scheme for the ‘social marketing’ of ORT had backfired. They told people what was in the plastic bags and apologized for tricking them by adding the Kool-Aid. They taught people how to make effective rehydration drinks with common ingredients in their own homes.
Over the next few years the Piaxtla team developed hands-on, discovery-based learning methods and aids to demystify knowledge about dehydration and rehydration. They helped parents and children clearly understand why giving a kid with diarrhea plenty of drink and food is so important and why a simple homemade solution often works better than losing time and money by going a long way for unnecessary medicines—or commercial packets of sugar and salts that have been made to look like medicine.
For parents who can read and write—or whose children can—health workers made simple, illustrated sheets showing how to prepare and give a “special drink” for diarrhea in the home. These instructions were eventually included in the villagers’ health care handbook, Where There Is No Doctor. Other ORT-related teaching methods and aids-such as use of the Gourd Baby-are described in Helping Health Workers Learn.
Another mistake by Piaxtla: For years the Piaxtla team promoted salt and sugar home mix. Then they made another discovery. Researchers in Bangladesh and elsewhere had shown that ORT drinks made with rice or other starchy foods combat dehydration better than drinks made with sugar and salt (or with glucose and salt, as WHO prescribes though its commercial ORS packets ).
So the Piaxtla team made another big shift in its recommendations, placing the technology even more in the people’s hands. Traditionally in Mexico, as in many parts of the world, village mothers have used rice water and other cereal drinks to treat children’s diarrhea. Unaware of the value of such drinks, the Piaxtla team had followed the UNICEF-WHO guidelines, teaching mothers that sugar-based drinks work better. But now, the latest research confirms the value of traditional cereal drinks. ORT drinks made from rice powder, maize meal, or mashed potato can rehydrate a child more quickly and safely than do sugar-based solutions. So today Piaxtla’s health workers, build on the local traditions: they encourage mothers to treat diarrhea with rice or maize based drinks.
Most import of all, however, is to give the drink in large quantities, and also to give food as soon as the sick child will take it. (Food not only provides energy to fight the illness and prevent weight loss, but also speeds rehydration.)
The Piaxtla team uses the lessons learned from its mistakes to help people take a rational approach to ORT… and to rediscover the value of certain traditional forms of healing.
Promotion of ORT on an International Scale.
Throughout the Third World many community-based programs have come to conclusions similar to Project Piaxtla. They, too, try to demedicalize and demystify oral rehydration, to put technology in the people’s hands.
By contrast, most large government programs still promote ORT as a pre-packaged “medicine.” This they mystify, calling it “Oral Rehydration Salts” (ORS) or “electrolytes.” These are manufactured and distributed in silvery packets called “sachets.” Originally they were made available free in health centers. But as poor countries were increasingly pressured by the World Bank to slash health budgets, ORS production and distribution has largely been privatized. This combined pharmaceuticalization and commercialization of the ‘simple solution’ has led to an unnecessary dependency and needless expense for poorfamilies. It partly explains the continued high incidence of preventable death from diarrhea.
Promoting factory-produced ORS packets rather than teaching people to use effective home drinks creates dependency on a product that is often not available when needed. The following true story from Africa makes this tragically clear.
Story #3: A Deadly Solution for a Mother in Kenya
An instructor of health workers in a rural health program in Kenya, Africa, told me (David Werner) how she discovered it was better to teach people to make their own home drinks, rather than to depend on ORS packets. One day when she was visiting a rural health post, a young mother arrived, exhausted from the long walk in the scorching sun. On her back was a baby wrapped in a shawl. She had come on foot from an isolated hut five miles away. She said she had walked rapidly, because her baby was very ill with ‘running stomach.’ The mother begged the health worker for the life saving medicine in the silver envelope she had heard about on the radio.
But when the mother unwrapped her baby, she saw he was dead. His body was shriveled and eyes sunken from dehydration. The long trip in the hot sun had been too much for him.
“I felt partly responsible,” said the instructor. “If we had taught her to make a rehydration drink at home, instead of telling her she needed to come to the health post for a magic drug, her baby might still be alive…
“They tell us the packets are safer and more effective. But that’s nonsense!” grumbled the aging instructor. “What is safest is what will save the most lives. And that is what mothers can do easiest and fastest in their homes. In our circumstances a homemade drink is safer. If you ask me, ORS packets are downright dangerous!”
She looked at me piercingly. “What I mean is that makin folks believe that ORS packets are superior to what they can provide in their own homes is dangerous. And that’s exactly what the big government programs are doing. It’s what we did ourselves, until we learned the hard way. Do you understand what I mean?”
Why So Many Children Still Die from Diarrhea—A Search for More Appropriate Solutions
Scores of small community programs in many poor countries have chosen to promote homemade drinks while discouraging use of packets. But with the international Child Survival network churning out 400 million packets a year, it is an uphill battle.
Twelve million children continue to die every year. Their deaths are related to poverty and undernutrition, perpetuated by inequitable socio-economic structures. In spite of all the high level talk about “Health for All” and “Child Survival,” the rights of children are being systematically and cruelly denied on a massive scale. Yet global planners continue to put the profits of the powerful before the basic needs of the majority. The gap is growing between rich and poor, within countries and between them. Technological solutions such as ORT and immunization, while important measures, are no substitute for fairer social structures.
It is time to analyze the shortcomings of conventional health and development strategies and to look for new solutions, not only to reduce child deaths, but to work toward a sustainable global community where quality of life of all children is valued and fostered.