|Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 pages)|
|Module Two: Diarrhea, dehydration and rehydration|
|Session 5 - Rehydration therapy|
In remote Sulla, a deprived area of Sylhet district in Bangladesh, an epidemic of diarrhoea among young children prompted an emergency do-it-yourself solution. That "solution" - salt, water, molasses - has proved a saviour of children's lives. By MEHR KAMAL
Sulla, a low-lying tract in Bangladesh's Sylhet district, is one of the poorest areas in the world. Here, farmers wrest one rice crop a year out of tiny plots of land. Most people, however, are landless and find only seasonal employment as farm hands or as fishermen when the rain-swollen rivers spill over, converting the marshy area into a vast monsoon lake.
So remote and neglected is Sulla that few Bangladeshis have heard of it. In 19 72, when a local non-governmental organization, the Bangladesh Rural Advancement Commitee (BRAC), began rehabilitating destitute refugees returning home after the creation of Bangladesh, it chose Sulla as a base of operations because of its extreme deprivation.
But BRAC workers arriving there were immediately faced with another more urgent problem as a diarrhoea epidemic broke out and hundreds of children began to die of dehydration and malnutrition. With no health services or pharmacies to rely on for support. in dealing with the problem) they prepared oral rehydration solutions for the children with salt, molasses and water, all of which were available even in the poorest homes.
This simple treatment - approved by the International Centre for Diarrhoeal Disease Research in Bangladesh (ICDDRB), the world's leading institution for research on diarrhoeal diseases-and BRAC'S method of teaching mothers how to use it, are now generally recognized as the best hope for an early reduction in infant deaths in Bangladesh.
Of every 1,000 children born alive in the country, some 140 die before reaching their first birthday, approximately half of them from complications such as dehydration and severe malnutrition connected with diarrhoea. While not a serious problem in itself, since the body purges itself of most diarrhoeal infections without any medication, diarrhoea can be devasting to a small child because essential fluids, minerals and nutrients are sometimes expelled from the body in a day. In Bangladesh, most of the 17,000 children who lose their eye-sight every year do so because diarrhoea drains away their already meagre reserves of vitamin A.
The treatment for diarrhoea is simple. A solution of salt, glucose and electrolytes mixed with water and taken orally can help to reverse dehydration. In Bangladesh, the Government is packaging oral rehydration salts (ORS) at four national centres assisted by UNICEF. These are then distributed free through the health services, and commercially-produced ORS packets are sold in dispensaries.
The total national production of ORS is not enough to meet the need. But stepping up production would address only a small part of the problem of getting mothers to use ORS when they should. In one of the world's least developed countries, health services reach only 21 per cent of the people and the nine out of ten people who live in rural areas have no access to pharmacies because these exist only in urban or semi-urban areas.
In addition, only 14 per cent of Bangladeshi women are literate and thus able to read the instructions for mixing the solution. At prices ranging from a few cents to over one dollar a packet, the cost may also be prohibitive, since the annual GNP per capita is only US$110, and four out of every five people live below the official poverty line.
Overcoming the hurdles
In Sulla, BRAC devised a programme which overcame ail of these hurdles. Since the accurate measurement of ingredients is crucial to the success of the therapy, it chose the method that most rural South Asian women use in measuring ingredients for cooking: their fingers.
The only spoon available in many homes is a wooden ladle used for stirring and serving, and women judge the proportion of spices required by pinches and heaps. BRAC therefore suggested a three-finger pinch of salt and a handful! of molasses mixed with an appropriate quantity of water.
Next, BRAC concentrated on one of the most difficult aspects of the problem: a change in attitudes and ingrained habits. Many Bangladeshi women believe that diarrhoea is either an air-borne affliction or is caused by evil spirits. So they hide the problem until it becomes severe. Doctors at the ICDDRB say that, at this stage, death can be only hours away, particularly for under-nourished children. Dehydration is accelerated by the fact that most mothers deny their children food and water during diarrhoea in the hope that this will stop the runny stool.
BRAC devised a simple flip chart which explained the connection between diarrhoea and dehydration by likening a child suffering from diarrhoea to a pitcher of water with a hole in the bottom. Armed with these, a ream of seven girls, who received five days training in diarrhoea management, went from house to house in Sulla, stressing the importance of rehydration from the moment the first loose motion begins.
With ingredients provided by the mother, they demonstrated the proper way to prepare a solution in a utensil available in the home. At the end of the session, the inside of the container was scratched to mark the appropriate water level, and a discussion ensued on the prevention of diarrhoea.
Each team was preceded by male workers who talked to the men about diarrhoea, and the "doctor" who will come to teach mothers how to treat it. Such persuasion was crucial to gaining the confidence of the community and giving the female workers access to all families.
One of the workers, 23-year-old Rooma, says that while mothers almost always accept the treatment, persuading them to take appropriate steps to prevent diarrhoea is hard. She cites the case of Mumtaz Begum whom she has just visited.
Mumtaz is one of the very few rural Bangladeshis lucky enough to have access to both a tubewell and a latrine. Yet, ignorant of the connection between clean water and sanitation and her children's frequent diarrhoea, she uses neither. The tubewell water is rejected because its high mineral content gives it a "peculiar" taste and the latrine her brother constructed when he came home for a visit from Dubai is regarded as a quaint city facility.
When pressed to wash her hands frequently with soap, Mumtaz said that her husband who sells vegetables in the village earns only Taka 30, U.S. $1.20, a day. This, supplemented with occasional remittances from Dubai, is barely enough to buy food. At 20 cents a bar, soap is a luxury they cannot afford on a daily basis.
In Bangladesh, diarrhoea will continue to be a major health hazard as its prevention requires the installation of millions of new tubewells and latrines, as well as a massive health education effort designed to motivate people to use them. The BRAC method of oral rehydration therapy with its home-made solution and house-to-house instruction is therefore winning widespread support. The experiment begun in Sulla, was extended in 1980 to cover five districts. In October 1983, it will enter its second phase, covering another seven of the country's 20 districts by June 1986.
It will take time to wipe out the agony of diarrhoea in Bangladesh, a land where medical historians believe cholera was reported for lee first time ever in the seventeenth century. But random surveys of its own programme carried out by BRAC have shown very positive results. Three months after receiving initial instructions, some 90 per cent of mothers have been able to answer all questions about diarrhoea correctly, and approximately 82 per cent have been able to prepare accurate oral rehydration solutions. Mizanur Rehman Chaudhry, BRAC'S area manager in Sylhet, claims that, at the cost of Taka 7 (U.S. 29 cents) per mother trained, this could be the most cost effective health programme anywhere.