A village recently experienced a food poisoning outbreak. It began in the usual way - with a festive gathering and unsanitary food handling. Within a day of the event, scores of people started showing symptoms, most significantly, diarrhea. Children and older people were affected most severely, with some requiring hospitalization. However, health workers gave most of the patients who came to the local sub-center small sachets of a powder, directions on how to mix it in water, and sent them home.
Half a century ago, a similar situation would have brought about panic, dismay, and hopelessness within the community. One of the most feared causes of death, over five million children succumbed to diarrhoea each year. Despite ongoing research, the only known treatment, intravenous (IV) rehydration, was available only in selected centers worldwide. This modality was neither accessible nor feasible in developing countries, especially during community outbreaks of transmissible gut infections. People tested several oral therapies — carrot soup, carob flour, dehydrated bananas, even " starvation periods" — without substantive success.
The most feared of these infections was "blue death," or cholera. A very rapidly developing and highly infectious disease, cholera decimated entire populations within days. All this must have been in Dr. Dilip Mahalanabis's mind as he set up a field hospital along the India-Bangladesh border in the aftermath of the 1971 war. Refugee camps had no access to clean water or sanitation and were soon struck by cholera.
Soon, the field hospitals ran out of supplies for IV saline treatment. With a shortage of equipment and trained personnel, Dr. Mahalanabis chose an unconventional route. His team created bags of salt-glucose mixtures and recruited healthy family members to formulate an oral solution, which they distributed among the patients. They also shared the composition with other camps plagued by the same disease. This mass treatment yielded near-miraculous results—the death rate from cholera dropped from 30% to 3.6% when compared to IV therapy.
The proof is in the pudding. Dr. Mahalanabis decision to start oral treatment for severe dehydration breathed new life into existing bodies of work. Although trials in controlled settings with limited patients existed, the impact made along the India-Bangladesh border resonated worldwide. Spurred on by the work of doctors worldwide, oral rehydration solution — better known as ORS — became the backbone of the WHO's Control of Diarrhoeal Disease (CDD) program in 1978. Today, UNICEF distributes almost 100 million sachets of ORS annually.
A Miracle Public Health Tool
Fifty years later, ORS remains an ideal public health tool because it is accessible, affordable, and usable with minimal training and is acceptable to the community. The WHO maintains and modifies a standard formulation of common ingredients, making it replicable in resource-poor settings under proper guidance. Being markedly cheaper than other treatment interventions, it is more affordable for both patients and public health funds.
A cadre of trained community health workers can easily transfer necessary knowledge to caregivers. Home-based care, with early recognition of warning signs, helps provide healthcare systematically using a bottom-up approach. ORS is easy to use and administer, with almost no risks involved. This makes it readily acceptable to the layman.
The effects of ORS are readily perceptible. Despite initial skepticism, this low-tech therapy is a humble solution to one of the most significant health issues. A 32% reduction in mortality among children under five years old is attributed to ORS. It has also led to decreased rates of hospitalization due to diarrhea. While its use for acute bouts of diarrhea is well-established, it is also indispensable in the treatment of malnutrition, which is intricately linked to chronic diarrhea.
ORS is said to have saved the lives of 50 million children worldwide.
Universal coverage of ORS can reduce up to 93% of deaths due to diarrhea, which still causes over 1.6 million deaths worldwide each year.
Barriers to ORS Usage
Despite being an effective tool, especially in the current context of rising temperatures and heat waves raging across the country, there are barriers to access for ORS. In 2012, only 22% of Indians had access to ORS. While extensive health initiatives increased the number to 48% by 2016, we still have a long way to go.
Secondly, people—both practitioners and patients—underestimate the effectiveness of ORS. Hence, despite mounting evidence against the empirical use of antibiotics for diarrhea, irrational antibiotic prescriptions continue when only supportive therapy with zinc and ORS would suffice. This leads to an increase in drug-resistant microbes in the community and also fails to convey the benefits of ORS to patients.
There is also a lack of robust knowledge, both among providers and patients, about how and how much ORS to use. This can lead to incomplete advice to caregivers. Home-based care can only be successful when imparted accurately. Along with training, periodic refresher courses are also necessary to maintain a competent workforce in the community.
There is also a public-private health system divide in the use of ORS. Data show that over time, there has been a decrease in ORS usage among patients visiting the private sector. This may be because, although private professionals prescribe ORS, they don't dispense it on their premises. Coupled with the public's underestimation of the benefits of ORS, this could lead people to choose not to take it. This contrasts with public health centers, which commonly provide sachets on the spot.
Finally, the usual demographic target for ORS dispensation by the government has been children. This is because deaths due to diarrhea have historically been higher in children, primarily in the under-5 population. As the rate of deaths due to diarrhea decreases and natural lifespans increase, the elderly population has become more vulnerable to diarrheal deaths. Furthermore, climate change and the susceptibility of diverse populations to heat-related illnesses have now made ORS a relevant tool for caring for everyone. This assumption that education about ORS needs to focus on children must give way to allow for the expansion of its use for all populations.
Through all odds, the conception of ORS revolutionized the treatment of dehydration. As research continues to find more efficient rehydration solutions, the original composition is being revised and improved. Meanwhile, increasing the number of people who have access to and know how to use ORS properly is imperative. Remembering that the fanciest answer isn't always the best is also helpful. As modern health practices and glitzy hospital buildings grow, we need to remind ourselves to keep things simple sometimes.
Edited by Christianez Ratna Kiruba
Image by Janvi Bokoliya
