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The roots of inaction: Understanding and overcoming the obstacles to greater investment in scaling-up effective diarrhea treatment

In the second 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.

As I have described the potential impact of scaling-up zinc and ORS to potential supporters over the past year, I have been frequently met with a what’s-the-catch wariness as if we are selling a sure-thing stock: if this is such a great opportunity, why hasn’t everyone else jumped on it? There are certainly some who have championed zinc and ORS over the past decade and made remarkable gains given the obstacles, but their voices have generally been drowned in a sea of indifference. I cannot provide them with a clear answer why much of the global health community has ignored this opportunity other than there are inefficiencies in every public policy process. But I do share the several principal arguments that we have found are used to explain the lack of attention to diarrhea treatment over the past two decades and our conclusion that none of them withstand scrutiny.

The first argument is that the world has attempted to scale-up ORS before and failed so it would be wasteful to try again.  In the 1980s and early 1990s, WHO and UNICEF led a global campaign to increase use of ORS, with the goal of reaching at least 80% child diarrheal episodes by 1995. They did not reach the global goal and the effort was eventually abandoned and country diarrhea programs were dismantled. But ORS use increased dramatically around the world, nearing or reaching the target in a range of countries from Bangladesh to Egypt to Zimbabwe and playing a central role in the reduction of diarrhea-related deaths by more than three million per year between 1980 and 2000. If only global health were filled with more such failures.

The history of malaria control offers an explanation for this seemingly strange fatalism. The Global Malaria Eradication Program is considered one of the greatest failures in the history of global public health. Through the intensive interventions spurred by the Program, countries across Asia, Eastern Europe, and Latin America dramatically reduced malaria transmission, freeing an estimated 1 billion people from the threat of the disease. In India, for example, annual malaria cases fell from 75 million to 100,000 (a 99.9% decline). Many countries, however, did not reach the ultimate goal of fully eliminating the disease and so the effort was dubbed a failure, funding was withdrawn, and malaria was largely neglected for two decades during which many of the gains achieved during the Program were lost.

Today, malaria is considered one of the major success stories in global health because of the 50% reductions in the disease achieved by a range of African countries. For the same disease a 99% reduction is a failure and 50% a resounding success? The difference is expectations. The recent effort set out with a goal of reducing the disease by 50% compared to the original moon-shot of eradication. So the message from global health leaders and funders would seem to be one given to every entry-level management consultant: under-promise and over-deliver. That is sound advice, but not cause to ignore an opportunity to cost-effectively and dramatically reduce child mortality around the world.

A second argument commonly used against investing more in zinc and ORS scale-up is that the products are flawed. Since they do not fully stop the diarrhea and are not “true” medicines – priorities emphasized by mothers in surveys – there is no doubt that both zinc and ORS are sub-optimal. But so are many of the products that form the cornerstone of modern public health programs. Bed nets are stifling to sleep under in tropical heat, pneumonia vaccines prevent only a portion of the disease, and new malaria treatments require many more pills than their still prevalent predecessors.  These and similar products have received billions of dollars of investment by international donors and have been widely adopted by their targets populations despite their flaws.

And as any consumer-oriented company knows well, products are not static (consider the number of versions of soft drinks, burgers, or tacos that have cycled through our lives over the past ten years). Manufacturers have already been innovating to increase the appeal of the products such as by creating pre-mixed “juice box” versions of ORS to eliminate the need to find clean water. A growing body of consumer research shows that while mothers want products that stop the diarrhea and are easily administered, their greatest priority is, unsurprisingly, to ensure their child survives and thrives. In most cases, zinc and ORS meet that goal while antibiotics do not.  However, that difference is often invisible to mothers and health providers (many diarrhea cases are non-fatal and self-resolving so a natural recovery can seem to be the effect of a drug), which has perpetuated the bias towards antibiotics. A similar phenomenon drives much of the overuse of antibiotics in the US. Overcoming this dynamic will not be easy, but with all of the expertise that now exists in selling people things they don’t need, surely we can find efficient ways to sell them inexpensive treatments they do need.

The final argument is that, unlike vaccines, there are no established delivery channels to increase zinc and ORS use. This is a narrow perspective. While the ability of formal public health systems to increase coverage of zinc and ORS is indeed constrained in many countries, our experience in Gujarat is typical: informal private providers deliver diarrhea treatment to large portions of the population. The pathways to reach most children with diarrhea exist; we just need to ensure they are delivering the right products. These private channels can be more challenging and intimidating than those for vaccines and other global public health staples since they are typically composed of thousands of independent and diffuse actors. But recent experiments in increasing the use of more effective anti-malarial medicines have demonstrated that those actors can rapidly, efficiently and affordably increase access to targeted products if the right incentives are in place.

An Optimal Investment

Sitting with the FHI 360 team at the end of the day over tea, I am reminded of the aspect of the zinc and ORS scale-up opportunity that ultimately cemented my resolve to support it: there is so little to lose and so much to gain. The world is investing billions of dollars each year to overcome pressing and complex global health challenges, from increasing access to life-extending AIDS treatment to developing new vaccines. These are vital investments and, indeed, when put in the context of our spending on other priorities ($2.4 billion for a single stealth bomber, for example), we should be investing billions more.

But compared to these priorities, ensuring widespread use of zinc and ORS is a bargain. A global effort led by UNICEF, the Clinton Health Access Initiative (CHAI), and others found that an intensive push to increase use of these products in the ten highest burden countries in the world (accounting for nearly two-thirds of global deaths due to diarrhea) would cost less than $20 million per country each year on average, equating to a few dollars per child treated and a few hundred dollars for every death prevented. The FHI 360 program does not need to run complex studies (there is extensive evidence showing zinc and ORS work, we just need to ensure people use them) or purchase and distribute expensive products (the small cost of these treatments is already being paid by the patients themselves, but for inappropriate drugs). Their costs are primarily just the shoe leather and strong management to canvas health providers and convincingly promote the treatments.

This analysis may be wrong. The barriers to large-scale use of zinc and ORS may be insurmountable and that seemingly innocuous yellow pill and its brethren may continue to be the norm here despite the concerted efforts of people like the team I have been shadowing. If so, the world will have lost a small fraction of the total resources devoted to global health priorities. But if these programs are successful, the impact will be massive, averting the deaths of hundreds of thousands of children. Low risk, high return – every investor’s dream. Too good to be true? Let’s find out.

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.


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