Diarrhea deaths are falling but ORS use still stagnant

This was originally published on Global Health TV on October 28, 2015.

I’m grateful to Chelsea Clinton for her admission that she is “obsessed with diarrhea,” and her total lack of embarrassment in bringing it up repeatedly. In an interview with Fast Company, it was the first thing she wanted to talk about.

I’m grateful to her because she is, as far, as I know, the only well-known public figure to champion the prevention and treatment of diarrhea, the world’s second biggest killer of children under five years old, even though we have cheap and effective ways of dealing with it.

“It’s completely unacceptable that more than 750,000 children die every year because of severe dehydration due to diarrhea,” said Clinton last year. “I just think that’s unconscionable.”

We need more champions of the diarrhea issue.

Four years ago, I wrote a blog bemoaning the fact that oral rehydration therapy (ORT) seemed to be on life support, even though The Lancet once called it “the most important medical advance of the 20^th century.” ORT and its practical application, oral rehydration solution (ORS), have long been found to be both effective and cost-effective in treating the dehydration caused by diarrhea.

Bangladesh is perhaps the best example of a country that has made stellar progress in fighting diarrhea through ORS. The treatment of diarrhea increased from 58% in 1993 to 81% in 2011.  Productive collaborations between the government, the private sector and organizations like the Social Marketing Company, which used social marketing revenues to build Bangladesh’s first ORS factory in 2004, have led to tremendous improvements in diarrheal disease management.

Starting in the 1970s, ORS has saved an estimated 50 million lives, costing less than $0.30 per sachet, according to the WHO. In 1978, the World Health Organization (WHO) established the Control of Diarrheal Diseases Program, and by the early 1980s, most developing countries had their own dedicated national programs.

But even though ORS was cheap and effective, the global health community moved on to other diseases, like AIDS and malaria. In the 1990s, these diarrheal disease programs were merged into broader child health programming, and lost their dedicated funding, staff, and systems. A 2008 analysis that looked at changes in ORS use in children under three found declines in 23 countries and increases in only 11.

A 2009 research study conducted by PATH, a leading NGO working to fight diarrhea, to evaluate the funding and policy landscape found that “diarrheal disease ranked last among a list of other global health issues.”

After years of neglect, diarrhea is back on the global health map. Diarrhea deaths among children under five are down from 700,000 per year in 2011 to around 531,000 in 2015, according to PATH, a drop of 24% in four years. The bad news is that ORS use has stagnated, says PATH, at around 35% over the last 10-15 years.

Why has diarrhea death dropped even though ORS has stagnated?

“It’s been because of increasing access to a set of protection, prevention and treatment interventions,” said Ashley Latimer, senior policy and advocacy officer at PATH. “More children are being vaccinated against rotavirus (a leading cause of diarrhea). Understanding the importance of hand-washing and clean drinking water is improving. Improved nutrition and exclusive breastfeeding probably plays a small role.”

In 2013, the WHO and UNICEF published “Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025,” the first-ever global plan to tackle the two diseases that take the lives of 2 million children every year, which was supported by more than 100 nongovernmental organizations.

There are several efforts underway to fight diarrhea more effectively.

For example, PATH is working to improve the formulation of ORS to make its benefits more apparent to caregivers.

“Reimagining global health” recently highlighted “30 high-impact innovations to save lives.” One of them (see Page 17) included several new treatments to reduce the burden of severe diarrhea, such as DiaResQ, which supplements the use of ORS and provides nutrients for intestinal repair.

An already established innovation is to create “comprehensive diarrhea treatment” by combining zinc with ORS. Zinc is a vital micronutrient that helps the body absorb water and electrolytes, reduces the duration and severity of diarrhea and prevents subsequent infections in the two to three months following treatment. Diarrhea mortality is reduced by 23% when zinc is administered with ORS. Unfortunately, use of zinc is even worse than ORS – only 5% as compared to 35% for ORS.

Diarrheal disease research and development funding is increasing modestly. In 2013, it was $200 million, up from $170 million in 2012. As in previous years, the top three funders accounted for almost three-quarters of total funding – the Bill & Melinda Gates Foundation (25% of funding), the U.S. National Institutes of Health (23%) and industry (22%).

“With the introduction of rotavirus vaccines and advances in WASH interventions, these are exciting times,” said Deborah Kidd, senior communications officer at PATH. “However, what is often overlooked is the burden of diarrhea morbidity among children in the developing world. Chronic, repeated infections, resulting malnutrition and stunted development, and the persistent economic burden on the family all contribute to a destructive cycle that keeps families in poverty. So it’s great news that deaths are declining, but that the problem of childhood diarrhea and its long-term consequences are far from solved.”

UNICEF reports that improvements in drinking water, sanitation and hygiene are reducing diarrheal disease (90% of the world’s population use improved drinking water sources and two-thirds use improve sanitation facilities).

However, the decline in diarrhea deaths should be no cause for complacency: UNICEF also reports that when children do fall ill with diarrhea, only two in five children receive appropriate treatment, including ORS.

Unlike many diseases, for which no cure exists, the cure for diarrhea has been around for decades and is cheap and available. We just have to find the financial, technical and social means to get it to people who need it, and help them use it to protect the health of their families.

This infographic shows the status of the war against pneumonia and diarrhea in the world’s poorest children.