The rise and fall of a global health success story, and how the G8 can bring it back

This article was also published in The Huffington Post on May 23, 2011.

Lancet once called it “potentially the most important medical advance of the 20th century.” But in the 21^st century, oral rehydration therapy (ORT) — a simple, cost-effective treatment given at home using either packets of oral rehydration salts (ORS) or a simple home solution of sugar, salt and water — seems to be on life support. The result is the unnecessary deaths of children under five.

ORT and ORS are indisputable bright spots in global health: Almost a billion episodes of child diarrhea are treated with ORT annually, reducing child deaths from diarrheal disease by more than 50 percent, according to the U.S. Agency for International Development.

Since the 1970s, ORS has saved an estimated 50 million lives, costing less than US $0.30 per sachet, reported the World Health Organization in 2009. Among major causes of child death, it is now tied for second place, at 14%, with pneumonia.

ORT is also highly cost-effective. A 2005 British Medical Journal paper found that ORT was one of the interventions that “would be chosen on purely cost effectiveness grounds for any level of resource availability.” But after the success of ORT, its uptake has slowed and even reversed in some countries.  A 2008 analysis of the change in ORS use in children under 3 between 1992 and 2005 found declines in 23 countries and increases in only 11. Declines in ORT use seemed to occur despite overall improvements in awareness of ORS.

What happened? After the success of ORT in the 1980s and 1990s, the global health agenda shifted to AIDS and malaria and that increase in resources was not matched by other leading causes of childhood deaths, including diarrhea, even though diarrhea accounts for 14% of child deaths, compared to malaria with 8% and HIV with 2%.

“The Control Diarrheal Disease program generated both supply and demand for ORS and ORT through mass campaigns, training, procurement and distribution,” said Evan Simpson, a program officer of PATH who works on diarrheal disease. “All the pieces were there. But it was all built on support for the public sector from donors, and may not have created a true and sustainable market.”

Later this week, the G8 Summit will be held in Deauville, France and leaders will face a plethora of pressing issues. One of them will be whether or not they will sustain their support for the Muskoka Intiative, a $7.3 billion maternal, child and reproductive health plan launched with much fanfare and promises of more to come. But so far, the G8 host, French President Nicholas Sarkozy, has shown zero interest in the Muskoka Initiative even though his wife, Carla Bruni-Sarkozy, wrote this at the 2009 L’Aquila G8: “G8 leaders sparked a revolution in health for the poor. They must now resist the economic pressure to undo it.” However, health is barely mentioned in the G8 priorities of the French presidency. Yet ORT is a perfect example of the kind of proven intervention that the G8 could easily scale up in order to save millions of children’s lives cost-effectively.

I looked at two countries that showed very different trends in the 2008 analysis — Bangladesh, one of the countries where ORS use increased (albeit, slightly) between 2000 and 2004, and Kenya, where it declined by 32%, the largest of any of the 34 countries studied.

“It is an unfortunate case with diarrhea treatment in Kenya,” my friend Rehana Ahmed, a Pakistani physician who has been living eight years in Kenya, told me. “There was a huge push around ORT in the 1980s and 1990s — diarrheal disease control programs supported by the Ministry of Health, countries starting their own local production of ORS and a strong global commitment around improving diarrhea treatment. But with the move towards Integrated Management of Childhood Illnesses, the diarrheal disease control programs lost leadership at the country level and interest at the global level. It’s really unfortunately that we have an effective, easily delivered approach that has lost its flavor.”

Bangladesh has long been considered one of the world’s greatest ORT successes. At the UN Summit on the Millennium Development Goals (MDGs) last year, the UN bestowed an award on Bangladesh for significant progress in reducing child mortality.

I played a small role in ORT popularization in Bangladesh in the late 1990s when I served as the resident advisor to the Social Marketing Company, a large Bangladeshi non-profit organization that made a huge contribution to both home preparation of ORT and the social marketing of ORS at subsidized prices in retail outlets.

Although SMC sold more than 226 million sachets of ORS last year, ORT use overall has dwindled in Bangladesh. The 2007 Demographic and Health Survey showed that, since 2004, use of commercial ORS had increased 10% but the percent of children receiving ORT had changed little. And the percent receiving fluids decreased slightly.

My former colleague Perveen Rasheed, a former managing director of the SMC, recalls that the three pillars of Bangladesh’s success in maternal and child health were family planning, immunization and ORT. “The three worked in tandem,” she said. “The governments were committed, the donors were putting funds in the right places, at the right time, in the right amounts through the right implementers and programs. The hugely popular immunization and ORT brought the trust parents needed. Children were not dying in frightening numbers. Thus, adoption of family planning made sense.”

ORT use took off after a cyclone and tidal wave hit Bangladesh in 1991 and continued to grow through the 1990s. But in the 2000s, Perveen said, two things happened: First, donors cut back on communications (“Every year, a new cohort of people become parents. To suppose that they know about ORT because almost everyone else does was not strategic.”) Second, some of the communications around the introduction of zinc tablets was confusing and discouraged people from using ORS in conjunction with them.

As global health priorities shifted, so did attention away from diarrheal disease. Although diarrhea is one of the leading killers of children, it was no longer treated as a global priority, according to a 2009 PATH report:  “A 2008 research study conducted by PATH to evaluate global health funding and the policy landscape found that diarrheal disease ranked last among a list of other global health issues…Widespread adoption of proven, existing water, sanitation, hygiene and health interventions has been hampered by the lack of political leadership and commitment to fight diarrheal disease. In turn, this has led to a decline in funding and research.”

How do we turn this around and restore ORT to its rightful role as a deadly weapon against diarrheal disease? UNICEF says we have to “reinstate diarrhea prevention and treatment as a cornerstone of community-based primary health care.”

The good news is that there is nothing complicated about that doing that. We already have the technology, we know how to use it and it doesn’t cost much. All we have to do is find the political will to get it done. The G8 leaders are in an excellent position to make that happen next week in Deauville.

See a video of how oral rehydration therapy is done from the PBS series, RX for Survival.