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PLOS BLOGS Speaking of Medicine and Health

Treating a deadly nuisance: On the trail of the simple yet elusive solution to the world’s second largest child-killer

In the first of two posts guest blogger Oliver Sabot from the Clinton Health Access Initiative reflects on the challenge and opportunity of scaling-up access to effective treatment for diarrhea, the second largest cause of child mortality globally. The posts reflect on a visit to a program to improve the use of zinc and oral rehydration salts to treat diarrhea in a rural area of the Indian state of Gujarat run by the nonprofit Family Health International 360.

Image Credit: Ellen Munro

“I give them the yellow pill,” says the shopkeeper, reaching across a counter piled high with boxes of painkillers, bottles of ointment, and a few tubs of massive bovine nutritional supplements, and opening his hand to reveal a single pill, the size of a tick, nestled in his palm. The pill is Loperamide, a staple of every Western traveler’s medicine kit, and it is our competition.

The team from nonprofit Family Health International 360 (FHI 360) and I have driven half the day to this one-room medicinal bazaar on the crowded, dusty track that serves as the main market street in this village in the Indian State of Gujarat to better understand what stands in the way of a renewed vision of ensuring widespread access to effective diarrhea treatment. The majority of children in Gujarat – and India overall – receive some form of treatment when they have diarrhea and two simple, inexpensive (less than $0.50) treatments, zinc and oral rehydration salts (ORS), can prevent almost all diarrhea-related deaths. But 200,000 children still die from the condition every year nationally – the second highest cause of child mortality. How is this possible in a country that is on pace to become an economic superpower?

The shopkeeper and his pill provide the clearest explanation. Diarrhea presents itself as a nuisance, not a deadly threat (despite how those in the midst of a bad bout of travelers diarrhea may feel). For a thinly stretched mother, the first priority is to secure relief as efficiently as possible. Compared to the hours of traveling, long waits, and empty shelves that typify a visit to a formal clinic, the ubiquitous shops and informal private doctors provide the convenience she seeks – an estimated 80% of mothers across the country first seek diarrhea care from private health providers.

Down the street, passing more than a half dozen similar shops along the way, we duck into a converted shipping container stocked only with a wall calendar, a small desk, and a wiry man with a suitcase full of medicines explaining how he relies on antibiotics to treat diarrhea. “Why?” inquires the promotional team managed by FHI 360 we are shadowing. With a self-conscious glance at our growing crowd in the mouth of his container, he quietly explains that they have the best chance of stopping the diarrhea, and then adds with a shrug that it is what he has always done. “Are you aware of the evidence of the impact zinc and ORS have on diarrhea and their endorsement by the World Health Organization and leading Indian pediatricians?” No. The exchange ends with the promotional team achieving their objective: the sale of a stack of zinc packages and a swap of mobile numbers for future orders.

Children are being treated for diarrhea, but they are just getting the wrong drugs. In most cases, the antibiotics and anti-diarrheal drugs that are the typical response to childhood diarrhea in India (given to roughly 60% of children with diarrhea) are at best useless and at worst actively harmful in most cases. Drugs like Loperamide work by paralyzing parts of the gastrointestinal tract, stopping everything – good or bad – from flowing out. For young children, this effect can be deadly: the drug was actively discouraged for use in children after six Pakistani children died in 1990 and a recent analysis found the drug caused severe side effects or death in around one percent of children. Yet mothers – and most health providers – here are not aware of these threats; they see only that the diarrhea decreases as they hoped and so drugs like these continue to do good business across India while less than two percent of children receive the recommended combination of zinc and ORS.

The challenge of increasing use of zinc and ORS over alternatives is similar to that faced by dozens of new drugs and other products every year. If zinc was a new blockbuster drug for male pattern baldness, pharmaceutical companies would deploy teams of agents to ensure that every doctor and anyone else who might influence sales was intimately familiar with the drug. But with their thin profit margins and primarily poor consumers, zinc and ORS do not attract the same intensive investment from companies.

FHI 360 has stepped in to fill the gap, supporting both small nonprofits and companies to deploy sales teams to promote zinc and ORS to every health provider. They have just begun in Gujarat, but the volume of sales we witness in just one day (all of the nearly dozen providers we visited bought some of the drugs, hopefully not only because of the foreigners eagerly observing the interactions through the doorway) leaves me optimistic that they can quickly gain ground and dethrone antibiotics and anti-diarrheals.

Recent experience in countries from Benin to Nepal suggests that simple interventions such as this can rapidly increase use of appropriate diarrhea treatment. No longer content to tinker with smaller-scale solutions, governments in India and a range of other countries with high diarrhea-related deaths have embarked on ambitious plans to dramatically increase national-scale use of zinc and ORS. The unprecedented efforts of these countries are backed by a surge of international attention and support from leaders in both the public and private sectors (zinc and ORS scale-up is a top priority for the MDG Health Alliance and the UN Commission on Life-saving Commodities, for example).

Even if they are only partially successful, these efforts have the potential to save the lives of hundreds of thousands of children (in the three highest burden states of India alone, every ten percent increase in use of zinc and ORS would save the lives of roughly 36,000 children by the end of 2015), offering one of the most cost-effective ways to accelerate progress towards the fourth Millennium Development Goal (reducing child mortality by two-thirds).

Oliver Sabot is an Executive Vice President at the Clinton Health Access Initiative, leading its work on treatment of diarrhea and malaria, among other programs. He serves as the chair of the market shaping workstream of the UN Commission on Life-saving Commodities and is the author of more than two dozen publications.

  1. This may put a thumb in one hole in the dyke at ground level but there are many other upstream issues that need fixing to address this and other problems.

    At say 1000 feet we have sanitation issues. At 2000 feet we have population control issues (access to contraceptives). At 3000 feet we have women’s empowerment issues and above everything we have education. I am not referring to “health education;” readin’ & writin’s the problem. If we impact on illiteracy we can impact on a thousand health problems; we have failed to address this and we do not have enough thumbs.

    We need to make basic education a health intervention. Doctors in white coats need to be visible leaders of this approach.

    Cuba has demonstrated that illiteracy can be eliminated (just like polio or small pox) in a relatively short time.

    Dr. Chen has called education of girls “the most cost effective health intervention.” This is true but doctors and other medical professionals have a limited set of “medical” interventions. Like the carpenter whose only tool is a hammer, we mistakenly use it (hammer drugs) to open bottles. We break a lot of bottles this way. Medical care does not address the major health problems. Education, sanitation, food and economic development do.

    The usual response is “But that’s not my area.” We better make it our area. We have the power – teachers do not.

  2. The health care providers are an important part of the solution to the problem of high childhood mortality caused by diarrhoea. However in Nigeria where i have just completed a study on care seeking behavior, it is important to consider what drives care seeking patterns. It is true that most of the children under five years are given some kind of treatment when they start having bouts of frequent loose stools which varies depending on the educational level of the primary caregiver as well as the best available option at that time. Quite a significant percentage of caregivers were found to use non formal methods like herbal preparations and rectal washouts at home as a first line of treatment.
    It would be very useful to give caregivers the necessary information to be able to help their children. Even if the zinc tablets and ORS are made available locally (as they are not available at the moment), unless they believe that it will help their children get better more efficiently, mothers (and grandmothers) would rather stick to the familiar routes of care. All this is in spite of the large resources that are apparently being put into setting up and running programs that control childhood diarrhoea.

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