SCIENCE / MEDICINE : Chance to Save Children Turns Into a Turf War : Disease: Doctors, aid agencies and government officials are at odds over which dietary supplement can best stave off dehydration. The ailment kills 5 million a year.
Diarrhea, according to the United Nations Childrens Fund (UNICEF), is the world’s leading cause of death of children under age 5. More accurately, it is the dehydration that can be a consequence of diarrhea that accounts for 5 million of the 14 million deaths of children under 5 occurring annually worldwide.
For more than a decade, UNICEF and other international agencies have conducted intensive programs in developing countries, where most of the deaths occur, promoting the use of a special preparation that can prevent the deadly dehydration. Called oral rehydration therapy (ORT), it consists of a mix of glucose and various salts, which a mother can mix with water and give to the child. Given soon enough and accompanied by food, the drink promotes changes in intestinal chemistry that blocks the potentially lethal dehydration.
In 1978, the British medical journal Lancet called oral rehydration “potentially the most important medical advance of this century.” Recently, instead of the traditional glucose and salts, ORT scientists have been testing a different preparation composed of cereals such as rice, sorghum, millet or corn mixed with water.
New reports by researchers indicating that the cereal gruel has life-saving advantages over the older formula is causing a heated debate within international agencies that conduct multimillion-dollar health programs in developing countries. Among the agencies are the U.S. Agency for International Development (USAID), the World Health Organization, UNICEF and health ministries in some countries.
On one side are scientists, doctors and some program managers who are convinced of the superiority of cereal-based ORT. On the other side are policy-makers from some agencies and health ministries that already have established national policies and implementation programs utilizing glucose-based ORT.
They believe introducing a new approach might confuse health workers and mothers. But the opponents have also been accused of bowing to pharmaceutical companies that prepare the glucose packets, which would suffer if homemade cereals take over.
According to a recent report prepared by UNICEF, the Aga Khan Foundation and the International Child Health Foundation, “cereal-based ORT is now recognized as an effective, practical, low cost, culturally acceptable and highly sensible health intervention (which is) appropriate to primary health care and child survival programs. . . .” The studies showed that cereal-based ORT is at least as effective as the glucose-based solution in preventing dehydration. Cereal ORT has the additional advantages over the glucose preparation of reducing the amount of diarrhea and vomiting and shortening the duration of illness, according to the report.
In addition, participants at a meeting on the subject late last year said mothers often do not use the glucose-based ORT because they see no visible change in the diarrhea and are unaware of the benefits occurring from rehydration. Advocates of the cereal formula pointed out that because it can be prepared at home it “exemplifies one of the best and most important methods of empowering families to take care of their own health without dependence on expensive and often non-existent or inaccessible health care services.”
Nevertheless, the cereal preparation may not be a panacea, and support for it is by no means unanimous. In a telephone interview, Kathleen Cravero, UNICEF’s senior adviser for diarrhea control, said the new approach is “a very encouraging development, very exciting, but more data is needed.” She said a chief concern is that mothers will neglect to give food along with cereal-based ORT because they inaccurately believe the cereal drink to be sufficient nutrition. Also, because much of the research to date has been on children with cholera, she said there is concern that youngsters with non-cholera diarrhea may not respond as well to cereal ORT.
Robert Clay, a USAID official, said his agency doesn’t think now is the time for governments to change their ORT policy. He said USAID recommends that more pilot studies be done at facilities where lots of non-cholera diarrhea is treated. “Our policy is to be optimistic about the cereal ORT, but we don’t want to throw out everything else because the cereal-based ORT does raise new concerns,” he said.
Advocates of the cereal preparation point out that continuing with the glucose formula also raises concerns. Despite the expenditure of hundreds of millions of dollars for promoting and distributing glucose ORT during the 1980s, some experts say that the program has failed to reach its expected potential.
In a booklet published in 1988, USAID claimed that oral rehydration therapy, combined with proper feeding, could save the lives of 4 million of the 5 million children who die of diarrhea dehydration every year. UNICEF’s estimate that 50% of the lives could be saved was more conservative. In 1987, UNICEF reported that rehydration therapy was saving 1 million children a year.
Between 1983 and 1985, USAID alone provided more than $67 million to assist ORT activities around the world. International agencies received much-deserved publicity for their efforts to supply ORT to millions of mothers in Africa, Asia and Latin America and to educate them to use it.
Initially, the promotion of oral rehydration therapy was based on making packets of the glucose-and-salt based formula available wherever health care is delivered within a country. Mothers were told to mix the ingredients with 1 liter of water and give it with food. In some places where the packets were not available, mothers were encouraged to make their own solutions using a special mix of sugar and salts, which are available in most homes.
A disadvantage of the homemade solution is that too much salt can kill the child. The logistics involved in educating the mothers of the 240 million children under age 3 in developing countries, plus the enormous task of supplying scores of countries with packets, has proved to be a formidable task.
Moreover, a World Health Organization committee reported last year that if each child required two to 10 packets each year, the 350 million packets being distributed annually could cover no more than 58% of the need for children under 3, not counting older children and adults who also need ORT. And, according to WHO, only 6% of health workers in developing countries have been trained to tell mothers how to use oral rehydration therapy.
Also, because of national funding shortages, many governments do not provide the packets free and people must buy them in local shops--or worse yet, buy other anti-diarrhea drugs that may be harmful. This also siphons off money better spent on food for the child, who very often is malnourished to begin with. Authorities have consistently tried to overcome the widespread--and incorrect--belief that it is best not to feed a child who suffers from diarrhea.
Deaths from diarrhea dehydration are not limited to developing countries. According to the International Child Health Foundation, dehydration kills about 500 children in the United States each year, most of them in poverty-stricken areas.
