DIARRHOEA DILEMMA

Item

Title
DIARRHOEA
DILEMMA
extracted text
Heal ch Bulletin No. 2

DIARRHOEA
DILEMMA

Health And Society Group

Oral Rehydration
The Principles, Practice and the Possibilities
Malathi Damodaran
Oral rehydration technique is one .of the most impor­
tant breakthroughs in the field of appropriate techno­
logy in health care. It is important not only because
.it is cheaper but because it proves that health care can
be simplified and demystified so that masses can take
care of their own health without medical sophistication.
This would be real ‘Health By the People?—Ed.
Malnutrition and diarrhoeal disease constitute two most
important causes of morbidity and mortality in young children
of the developing world. The effect of repeated attacks of
diarrhoea in producing and perpetuating malnutrition is well
established.
Acute watery diarrhoea is caused by a variety of bacterial
and viral agents. Some of these agents produce diarrhoea by
invading and reproducing within mucosal cells of the bowel
and damaging the mucosa, resulting in water and electrolyte
loss, while some others colonize the lumen and produce entero­
toxins. These different pathopysiological mechanisms produce
the disease, which is generally self limiting and is characte­
rized by :
1. Passing of isotonic fluid which may be similar to or
differ from plasma in the electrolyte content; depending on the
rate of output.
2. Disaccharidase deficiency also is noted during the diar­
rhoeal and early convalescent period.
Printed from Medico Friend Ciicle Bulletin
Nov. & Dec. 1979.

No. 47-8
3

I
Dehydration, the cause of immediate morbidity and morta­
lity in diarrhoea, occurs as a result of loss of fluids and elec­
trolytes from the body. When the loss is rapid and large and
the age younger, the dehydration may be severe, manifesting
as shock and leading to death. However, in a majority of
cases, the dehydration may be mild or moderate, manifesting
as increased thirst, decreased urine output, decreased skin
turgor and dryness of mucosa.
The long-term effects of repeated diarrhoeal attacks are
largely nutritional, and most pronounced in young children,
who have marginal food intake. The cumulative effects of
increased demands, protein catabolism and decreased intake
resulting from anorexia and often imposed fasting during the
illness, result in restricted growth and further exacerbation
of existing malnutrition.
Considering the immediate and long-term effects of diarr­
hoeal disease, the two major objectives in treating diarrhoea
would appear to be :
1. Early replacement of water and electrolyte losses to
prevent or treat dehydration.
2. Maintenance of adequate nutrition.
Fluid and Electrolytes Not the Drugs
Till the early seventies, the treatment of diarrhoea consisted of drug therapy, along with the use of intravenous fluids
to correct dehydration. Now it has been amply documented
that antibiotics are not useful in most cases of diarrhoea,
except those caused by vibrio cholerae and shigella and no
other chemotherapeutic agents have been shown to be useful
in treatment of diarrhoeal illness. Now it is clear that the
primary goal of treatment of diarrhoea is fluid and electrolyte
replacement. Intravenous therapy has the obvious disadvan­
tage of being expensive, and requiring trained personnel for
its administration. The use of this form of fluid replacement
would naturally have to be restricted to severe cases of
dehydration.

Oral therapy is based on the observation that glucose is
actively absorbed by the normal small bowel and that sodium
4
CH IH-0 '

Xfg-

is carried with it in an equimolar ratio. Thus, in the normal
intestine there is considerably greater net absorption of an
isotonic salt solution with glucose than of one without glucose.
During acute diarrhoea, the absorption of sodium is impaired
and administration of salt solution may enhance diarrhoea.
However, glucose absorption remains unimpaired and addition
of glucose to isotonic salt solution would facilitate the absorp­
tion of electrolytes.
The composition of oral fluid which has been widely and
effectively used and which is recommended by WHO is as
follows :
Sodium
90
mEq/lit
Potassium 20
,» ,»
Chloride
80
,,
Bicarbonate 30
• ,, ,,
Glucose
111 mM/lit
This is prepared by adding to one litre of water :
Sodium chloride
3. 5 g
Sodium bicarbonate 2. 5 g
Potassium chloride
1.5 g
Glucose
20 g
Simplification into a home remedy
Such a mixture is available commercially. It can be easily
prepared in health centres and dispensed in plastic bags, stored
in a dry condition. As an alternative, at the home level the
mothers can be taught to prepare the solution by adding |
teaspoon or 3 to 4 “.three finger pinches’’ of salt and 5 teas­
poons or a “four finger scoop” of sugar to one liter of water.
Once prepared, the solution should be used up within.a day.
The solution may be used as the sole therapy to rehydrate
patients with mild or moderate dehydration (who constitute a
majority) and also for maintaining hydration after rehydration
has been achieved. The patient is encouraged to drink as
much fluid as possible, thirst being a guide to the amount of
fluid required. Vomiting may occur, but can be overcome by
administering small amounts, frequently.
A number of studies in children and adults with cholera
5

and non-cholera diarrhoea have established the efficacy of oral
therapy in a hospital environment. The success of oral therapy
can be judged by the considerable reduction in the use of
intravenous fluids, thus bringing down the cost of treatment.
Fewer studies have been done on the use of oral therapy in an
outpatient setting. However, it is obvious that children with
mild-moderate dehydration can be rehydrated at a health
centre and sent home with instructions to the mother regard­
ing the continued use of oral fluid. '1 he instructions should
be clear and include use of accurate measurements of the
ingredients, if packets are not available as also the correct
measurements of water. The need to use up the solution with­
in 24 hours has to be stressed.
The real usefulness of oral therapy lies in the possibility
of using this approach in the home setting with minimum or
no medical supervision. Information about the usefulness and
safety of this approach used in this setting is scanty. It is
clear that this is a tool which can be used by the community
health workers, paramedical workers for minimising death
from diarrhoea.
There are presently some differences of opinion regarding
the optimal content of the oral fluid. While the ideal would
be to have an universal diarrhoea fluid, there are some who
doubt the advisability of the same. The main controversy
centres around the sodium content, which according to some,
may be too high for universal use. Since, the availability of
glucose is limited in some areas, sucrose has been suggested as
an alternate carbohydrate source. There is sufficient evidence
to show that sucrose can replace glucose.
Not to Forget Nutrition and Sanitation
A recent study in the Philippines has documented that
children with diarrhoea, particularly with recurrent episodes,
do better nutritionally vhen treated with oral fluids and con­
tinued food intake during the diarrhoeal episode. The major
effect of the oral fluid seems to be the quick reversal of nau­
sea, vomiting and anorexia, so much a part of the diarrhoeal
syndrome, thereby improving the food intake. However, this
6

observation needs to be substantiated further.
It seems obvious that while oral fluid corrects the fluid and
electrolyte imbalance, the long term effects of diarrhoea, nam­
ely malnutrition, can be prevented only by ensuring proper
food intake during and following the diarrhoeal attack. How­
ever, most of the mothers and many in the medical profession,
believe in starving the patients or giving dilute gruel during
diarrhoea. In some parts of the country water is forbidden
for infants and young children, especially during diarrhoea, as
it is believed to worsen the disease and also cause cold. The
wide-spread use of oral hydration would necessarily involve
studies regarding such practices and suitable modifications to
suit the local beliefs.
Oral hydration can at the best be considered as a tool to
reduce mortality from diarrhoea. However, the reduction of
the disease incidence can only be brought about other measu­
res such as protected water supply, sanitation measures and
health education to improve food and water handling practices
and personal hygiene. These measures can only form part of
overall socio-economic improvement and spread of education
and this can not be treated in isolation.

Oral Therapy for Acute Diarrhoea
SINCE the first controlled clinical trials of oral rehydra­
tion therapy <ORT) in 1967,1 studies in adults, children, and
infants have shown the efficacy of ORT in mild to severe acute
diarrhoeal disease of various aetiologies.2'"1 (The work of the
past fifteen years has been reviewed in two recent papers.5-6)
In many countries diarrhoea is the major cause of morbidity
and mortality in children under five, so the potential health
benefits of oral therapy are profound. RAHMAN and co-wor­
kers,7 in Bangladesh, have shown an up to fivefold reduction
in diarrhoea case fatality with a home-based ORT programme.
In India8 and Egypt9 similar ORT programmes have been asso­
ciated with a halving of diarrhoea-related mortality. Although
there may be argument over the magnitude of the gains, a
decline in the diarrhoea case fatality rate has been a consistent
finding when ORT has been accessible to the community and
properly used. Early therapy by mouth arrests and reverses
used. Early therapy by mouth arrests and reverses the pro­
gression to severe dehydration which might otherwise require
intravenous fluid. The World Health Organisation has recog­
nised that oral therapy may be the single most important step
in the development of programmes to manage diarrhoeal dise­
ase as well as a key to the reduction of infant and child mor­
bidity and mortality.10-11 Questions, however, remain. What
is the best formula ? How should it be packaged ? What health
care personnel are most appropriate for the dissemination of
ORT ? And what are the real effects of ORT on morbidity
and mortality ?
WHO has recommended a single oral, rehydration formula
Reprinted from The Lancet, Sept. 19, 1981

.8

for the management of deficits in water, base, sodium, and
potassium.10 The formula contains, in mmol per litre, 90 of
sodium, 25 of potassium, 80 of chloride, 30 of bicarbonate,
and 110 of glucose. Most experts regard this as a physiologi­
cally sound mixture that will ensure optimum salt and water
absorption for dehydration ranging from imperceptible to

severe. To accomplish the final concentration, two variables
must be considered—the quantity of salts and the volume of
water in which these salts are dissolved.
Stool sodiums are often less than 90 mmol/1, and some
workers maintain that the ORT should have a sodium of 60
mmol/1 or less.12 With the exception of rotavirus infections,
where there are stool sodium concentrations of 32±3
mmol/1,13 the higher the stool volume the higher the sodium
concentration and the greater the sodium deficit. The existing
formula, however, has proved satisfactory in clinical trials in
mild to severe diarrhoea when the sodium concentration in
stools was between 25 and J 25 mmol/1.1 * This preparation
has also shown itself safe irrespective of the aetiological agent.
Hypernatraemia has very seldom arisen. In fact, lowering the
sodium to 60 mmol/1 may entail a risk of prolonged hypona­
traemia.16 One reason that the formula has proved successful
is that the patient always receives additional sodium-free
water.13”16 Freewater may be given on demand or can be
given in a two-to-one regimen—that is, two parts of ORT
followed by one part of free water in an alternating pattern.
Giving water on demand seems as effective and is simpler.
Additional sodium-free water must not be directly added to
the formula for this lowers the sugar concentration to less
effective levels. Feeding the infant with breast milk also
reduces the final sodium concentration ; human milk has only
2~3 mmol of sodium per litre. In the treatment of rotavirus
diarrhoea, SACK et al.18 showed that ORT with 90 mmol
sodium per litre entailed no risk of hypernatraemia, even
though the stool sodium did not exceed 35 mmol/1.
Stool potassium losses tend to be higher ip children than
in adults and there can be substantial potassium loss during
medico friend circle
[orgenlzotlon & bulletin office]
326. V Main, 1st Block
Koramangalaf Bangalore-560034

,(9

diarrhoea. The recommended concentration of 25 mmol pota­
ssium per litre has been tolerated by all age groups ; children
have been treated with solutions containing 35 mmol/1 with
no adverse effects. Potassium losses may be partly compen­
sated with foods such as citrus fruits, green coconut water,
and bananas. Their potassium content is not, however, very
high and deficits may be difficult to correct.10 In severe diar­
rhoea inclusion of bicarbonate is very important to avoid
acidosis.17
Intestinal absorption of sodium and water in the diarj hoea
patient is enhanced by a facilitated co-transport mechanism.
Glucose is absorbed normally in the diarrhoea patient and is
the standard against which other sugars or aminoacids must
be measured in enhancing this transport. Except in severe
diarrhoea sucrose can be substituted for glucose with almost
comparable results. However, since only the glucose fraction
of sucrose is active in transport, twice as much sucrose must
be used. When a packaged mix is prepared at a central pro­
duction unit, glucose is preferable. Other substrates such as
the aminoacid, glycine, have proven very effective in controlled
balance studies ;18 but there have been no large-scale clinical
trials. The starches in rice, too, are very effective as substra­
tes in the oral therapy mix.19
How the ORT is delivered to the population will depend
on the health infrastructure. Where there is a good drug dis­
tribution system and containers can be standardised, centra­
lised packaging is recommended.11 When added to the correct
amount of water, a packaged mix gives the most accurate
concentrations. But production and distribution of packets
may greatly increase the expense of ORT—a serious matter in
poor countries. In addition, the distribution of health person-^
nel and supplies may be very uneven. In these situations, a
double spoon has been used which measures two ingredients
—sucrose and sodium chloride. Measurement with the spoon
is less accurate than dispensing from a packet, and potassium
and bicarbonate are not included. Despite these drawbacks,
community-based programmes employing the spoon have been

10

The stool takes
the shape of the
container

FIRSTLINE
treatment

Infants and young children
Rotavirus
Common world-wide in all socio­
economic groups
1
Peak in colder seasons in temperate
climates

Fever
Nausea
Vomiting Malaise
Severe
Abdominal dehydra­
tion
pain

0—72
hours

Infants and young children in
developing countries
Travellers diarrhoea in adults

Enterotoxigenic
Escherichia colic
(ETEC)

Rehydration
therapy

Malaise
Nausea
Vomiting
Fever
Chills
Abdominal
pain

8—80
hours

Children
Common world-wide
Food-borne outbreaks (animal
products)
Warmer seasons

Non-typhoid
Salmonellae

Rehydration
therapy

World-wide distribution
In developed countries may be
food-borne (animal products) or
transmitted by handling of animals

Campylobacter

Rehydration
therapy
Erythromycin
in severe cases

Children in endemic areas
Adults in newly affected areas
Not found in Latin America

Vibrio
cholerae

Rehydration
therapy
Tetracycline

Nursery outbreaks in developed
countries
Uncertain in developing countries

Enteropathogenic Rehydration
therapy
Escherichia
coll (EPEC)

Children
Poor hygiene
Malnutrition
Institutions
Warmer seasons

Shigellae

Rehydration
therapy
Ampicillin or
TrimethoprimSulphamethoxazole

days

Vomiting
Severe de­ 1—3
Abdominal hydration days
Circulatory
pain
collapse,
•shock’
Fever
6—72
Nausea
Vomiting
hours

The stool is soft
and watery with
blood and/or pus

ORGANISMS

24-72
hours

Abdominal Chills
pain
Blood and
Fever
pus in the
Malaise
stools

DYSENTERY

EPIDEMIOLOGICAL FEATURES

Severe
dehydra­
tion in
some

Vomiting
! Fever

ACUTE
WATERY
DIARRHOEA

INCUBA­
TION
PERIOD

86—72
Malaise
Fever
hours
Abdominal Vomiting
Urgency to
pain
defaecate

Painful
spasm on
defaecation

Abdominal
PROLONGED
discomfort
DIARRHOEA
(Or Dysentery)
Abdominal Anorexia
For at least 7days,
stools have been distension Nausea
more frequent or Flatulence Malab­
of softer consist­
sorption
ency ( with or
Frothy
without blood or
stools
pus)

<

Rehydration
therapy

2-6
weeks

All age groups
World-wide distribution

Entamoebo*
histolytica

Metronidazole

1-3
weeks

Young children
Some travellers
Poor hygiene
World-wide distribution

Glardia*
lamblia

Metronidazole

•Can be identified on examination of the stools with a light micro­ Produced in collaboration with the Ross Institute of the Lon­
cope. Blood and pus from Shigellae and Campylobacter can also don School of Hygiene and Tropical Medicine and The Save
the Children Fund.
be identified.

Reprinted from Diarrhoea Dialogue, issue 7, Nov. 1981

COMPLAINT

ASSOCIATED CLINI­
CAL FEATURES
COMMON OTHERS

quite successful in reducing mortality and morbidity. An even
simpler method is the pince of salt and scoop of sugar
method 20 No utensils are required and, if the mother is indi­
vidually trained and the training is periodically reinforced,
the final electrolyte composition falls within safe limits 98% of
the time. In general, the more accurate the ORT mix, the
more dependent will be the patient of the health delivery sys­
tem ; the less complete and standardised the mix, the more
accessible will be ORT. There are trade-offs in both directions.
The largest errors in the final electrolyte concentration
arise from measurement of the water rather than the salts.
What is needed is a standard container, whether in the hospi­
tal, the health centre, or the home.8 Among the suggestions
are sale of graduated plastic bottles at a subsidised rate, mar­
keting of the salts in an inexpensive standard container, use of
a container of known size such as a beer bottle or glass (such
a universal container is usually unavailable), and sending wor­
kers from house to house marking a container to show the
required volume. There is no substitute for direct interaction
between the health worker and the person who actually gives
the treatment. Though mass-media campaigns may sensitise
the population to the importance of oral therapy, mistakes
will be made if health workers and mothers do not receive
direct instruction.21 In Egypt, Bangladesh, and India the
effect of ORT on morbidity and mortality was attributed to
the intense interactions between health providers and mothers.
In addition to correcting and maintaining salt and water
balance, ORT has nutritional benefits in the child?2”24 Early
initiation of oral therapy seems to improve appetite • and
another important element almost certainly, is the push to
early feeding. Mothers were encouraged to continue breast­
feeding and resume a regular diet as soon as the child wanted
to eat.° Feeding improves nutrition without increasing the
severity or duration of diarrhoea.2^37 Continued feeding is
particularly important when malnutrition is common.
The benefits of ORT, then, are clear. It is effective, inexpensive, easily used, safer than intravenous therapy, and invol­

11

ves the mother in the child’s care. When it is combined with
continued feeding, and food intake is increased during reco­
very, nutritional status gets no worse or improves. Despite
these benefits, several countries have shown little enthusiasm
for ORT. Paediatricians in Europe and the U.S.A, generally
adopt a more traditional approach to diarrhoea-oral replace­
ment of stool loss with low-sodium fluids, limited food intake
during diarrhoea, and mor© reliance on intravenous fluid in the
moderately dehydrated child. Though diarrhoea is not the
killer in the West that it is in poor countries, it is still a subs­
tantial health problem ; more use should be made of the
experience gained from ORT therapy. What questions about
ORT still need to be tackled ? Other substrates might be
added to the oral therapy mix to improve absorption. Better
quantitative guidelines should be established for u eight resto­
ration and avoidance of milk intolerance. Techniques for
training health workers and mothers must be further explored
in various cultural settings. And it will be important to
evaluate the full impact of national ORT programmes on mor
tality and morbidity. If there is a tendency to overestimate
the impact of ORT on child mortality, this may lead to expec­
tations that cannot be met.
1. Nalin DR, Cash RA, Islam R, Molla M, Philips RA. Oral
maintenance therapy for cholera in adults, Lancet 1968 ;
ii : 370- 73.
2. Pierce NF, Sack RB, Mitra R, Banwell J, Brigham K,
Fedson D, Mondal A Replacement of electrolyte and water
losses in cholera by an oral glucose-electrolyte solution.
Ann Intern Med 1969 ; 70 : 1173—SI.
3. Mahalanabis D, Wallace CK, Kallen RJ, Mondal A, Pierce
NF. Water and electrolyte losses due to cholera in infants
and small children : a recovery balance study. Pediatrics
1970 : 45 : 374—85.
4. Pizarro D, Posada G, Mata L, Nalin D, Mohs E. Oral
rehydration of neonates with dehydrating diarrhoeas.
Lancet 1979 ; ii : 1209—10.
5. Oral rehydration therapy (ORT) for childhood diarrhea.
12

Population Reports 1980 ; November-December, series L,
no. 2, Population Information Program, Johns Hopkins
University.
,
6. Management of the diarrheal diseases at the community
level. Committee on International Nutrition Programs.
Washington, D.C. : National Academy of Sciences, Natio­
nal Academy Press 1981.
7. Rahman MM, Aziz KMS. Patwari X, Munshi MH. Diarr­
hoeal mortality in two Bahgladeshi villages with and with­
out community-based oral rehydration therapy. Lancet
1979 ; ii : 809—12.
8. Kielmann A A, McCord C. Home treatment of childhood
diarrea in Punjab villages. Environmental Child Health
1977 ; 23 : 197-201.
9. Mobarak MB, Hammamy MT, Gornaa Al, Abou-El-Saad
S, Lotfi RK, Mazen I, Nagati A, Kielmann AA. Diarrheal
Disease Control Study. Final report on phase I to USAID
and WHO, April 1981. Strengthening Rural Health Deli­
very Project, Ministry of Health, Arab Republic of Egypt.
10. A manual for the treatment of acute diarrhoea. World
Health Organisation, Programme for Control of Diarrhoeal
Diseases, Geneva : WHO/CDD/SER/80.2.
11. Guidelines for the production of oral rehydration salts.
World Health Organization. Programme for Control of
Diarrhoeal Diseases. Geneva : WHO/CDD/SER/80.3.
12. Bart KJ, Finberg L. Single solution for oral therapy of
diarrhoea. Lancet 1976 ; I : 633 34.
13. Sack DA, Chowdhury AMAK, Eusof A, Ali MA, Merson
MH Islam S, Black RE. Brown KH. Oral hydration in
rotavirus diarrhoea : a double blind comparison of sucrose
with glucose electrolyte solution. Lancet 1978 ; ii :

280 — 83.
14 Hirschhorn N.The treatment of acute diarrhea in children:
an historical and physiological perspective. Am J Clin
Nutr 1980 ; 33 : 637 — 63.
15. Nalin DR, Harland E, Ramlal A, Swaby D, McDonald J.
■
Gangarosa R, Levine M, Akierman A, Antoine M, Mac13

Kenzie K, Johnson B Comparison of low and high sodium
and potassium content in oral rehydration solutions. J
Pediat 1980 ; 97 : 848--53.
16. Clements ML, Levine MM, Black RE. Hughes TP, Kust J,
Tome FC. Potassium supplements for oral diarrhoea regi­
mes. Lancet 1980 ; ii : 854.
17. Islam MR. Greenough WB, Rahman MM, Choudhury
AMAK, Sack DA. Lobon-gur (common salt and brown)
sugar) oral rehydration solution in the diarrhoea of adults.
Dacca, Bangladesh, International Centre for Diarrhoeal
Disease Research, Bangladesh. April 1980. (Scientific
Report no. 36).
18. Nalin DR, Cash RA, Rahman M, Yunus M. Effect of gly­
cine and glusose on sodium and water absorption in
patients with cholera. Gut 1970 ; 11 : 768—72.
19. Molla M. In : Proceedings of the Workshop on the Inter­
actions of Diarrhea and Malnutrition : Pathophysiology,
Epidemiology, and Interventions, Bellagio, Italy, May
11—15, 1981.
20. Cutting WAM, Flierbrock TV. Homemade oral solutions
for diarrhoea. Lancet 1981 ; i : 998.
21. Guidelines for the trainers of community health workers
on the treatment and prevention of acute diarrhoea. World
Health Organisation, Programme for Control of Diarhoeal
Diseases, Geneva . WHO/CDD/SER/80.1.
22. Internationtl Study Group. Beneficial effects of oral electrolyte-sugar solutions in the treatment of children’s diar­
rhoea. I. Studies in two ambulatory care clinics. J Trap
Pediatr 1981 ; 27 : 62—67.
23. International Study Group. Beneficial effects of oral electrolyte-sugar solutions in the treatment of children’s
diarrhoea. 2. Studies in seven rural villages. J Trap
Pediatr 1981 ; 27 : 136—39.
24. Rowland MGM, Cole TJ. The effect of early hlucose-electrolyte therapy on diarrhoea and growth in rural Gambian
village children. J Trap Pediatr 1980 ; 26 : 54—57.
25. Chung AW. The effect of oral feeding at different levels on

14

the absorption of foodstuffs in infantile diarrhea. J Pedlar
1948 ; 33 : 1—13.
26. Chung AW, Viscorova B. The effect of early oral feeding
versus early oral starvation on the course of infantile
diarrhea. J Pediatr 1948 ; 33 : 14—22.
27. Molla A, Molla AM. Rahim A, Sarker SA, Mozaffar Z,
Rahman M. Intake and absorption of nutrients in children
with cholera and rotavirus infection during acute diarrhea
and after recovery. Dacca, Bangladesh, International Cen­
tre for Diarrhoeal Disease Research, Bangladesh (ICDDR,
B), 1980.

r

15

medico friend circle
[organization & bulletin office]
326, V Main, 1st Block
Koramangaia, Bangalore-560034

The Treatment of Diarrhoea
During the last five years there has been a lot of discussion
on the new concept of treating diarrhoea. The W.H.O. pro­
duced a nice little booklet on this subject in 1976, a quarterly
newsletter, “Diarrhoea dialogue” is being produced by a
W.H.O. collaborating centre. In its turn M. E.C. has published
an article, ‘‘oral rehydration” in the December 1979 issue of
its bulletin. We are familiar with the name of 0 R T, 0 R S
etc. We doctors have even memorised how many mEq of
sodium or potassium there are in one litre of W.H.O. recom­
mended oral fluid. So what of all this ? Pharmaceutical com­
panies are still producing rubbishy anti-diarrhoeals •, doctors
are prescribing ‘Chlorostrep’, ‘Pectokab’, ‘Streptomagma’, some­
times with ‘electral’ ; saline drips are immediately put up in
a bit more severely dehydrated cases ; ‘quacks’ are putting
up a saline drip for any case of diarrhoea and charging poor
villagers Rs. 80 or more.
With this background I want to fit in Somra somewhere—
I find it difficult. Somra wants to fit himself in the more re­
mote villages, in the distant village markets on his noisy old
bicycle with a tin box and pictures. He explains to the villa­
gers gathered round him, sometimes in tribal language and
sometimes in Hindi,—‘‘Take one litre of water, boil it, let it
cool, then add the whole content of the packet, stir it and
start drinking so long as the diarrhoea continues. In case of
vomiting ..” Tora can fill in this gap correctly. He knows
what to do in case of vomiting Once he brought his son, 12
years old, with severe diarrhoea and frequent vomiting. At
first, Tora went to Somra and started giving oral fluid, but the
vomiting was a nuisance. In the evening we again prepared
another litre of rehydration fluid and started feeding Tora’s
son with a teaspoon at exactly one minute interval. After five

16

r
stepped ter exactly dve minutes and started
SxVfc VP-va had adapted the time intervals and conti­
nued «* the s^me mnner throughout the night. In the morn­
ing. cbe boy wodxed buck hem? eue mile away with his father.
let xs return te Senuw Ue explains—“In ease of vomiting,
g<ve the £d;d $?<&<$ with a spoon like in the picture, but
m*ver stop <u;d in duvrhoeu and vomiting?’

Scmrx a v tl age health worker and it would not be an
exiggerat;n to say he has saved many lives with his rehydratreu. packets- lie knows this and so is concerned to make
them xs widely available as possible in remote village homes
•xT-i. m vr^xge SJiops and markets. His work seems far removed
mm those places where intellectual discussions take place
ab-mt 0 K T. where, tor example, the merits of oral rehydraxs x 's?me remedy*’ are expounded and it is explained.
that we muss not make villagers dependent on packets, we
m-n use kcal ingredients. ‘’But. Somra objects, in many
hones sum even is not available, do we then use salt and
water . In that ease it won’t be so good, the patient may not
improve and we will have to transport him to the centre for a
dziz to he pm up. Perhaps he will be given antibiotics and
anti-mamnc-eals too.” Somra knows that he can treat even
=ermus •lases whh his packets and without antibiotics and
anit-ilamniesG preparations. And more importantly, he is
a tool with which the villagers can fight against the
di-^ors and quacks who exploit them.

Even nnw, diarrhea is a killer in many villages in many
parts of India. In the villages, it does not only kill the pati­
ent bus his her family too. The exorbitant charge (often
betw^n
W> to
300 ) made by the doctor or a quack
maeh dTerence 1) for a «afine drip and a few injections of
'Vi% E-Zx>r*pz, ’Earafgan*, re^ultii in losing land, property,
Wlbas eao.^e^- d^rrhoea ? There in n<> doubt that well have
to find or>t t/x; cause (/V;tio /ethology *.) before going on to its

17

treatment. The answer is—insecurity’ and exoloitation in
earning, lack of proper housing and drinking water, ignorance
with superadded infection of enterovirus, shigella, E. coli and
what not.
Now treatment. We speak of anti-diarrhoeal preparations,
we say ‘’ban lomotil”, at best we try to adopt “scientific and
appropriate” oral rchydration therapy. In fact all our discus­
sions are centred around the secondary infection, we forget
the primary cause.
I know that I’m going into another discussion. Some may
objects that I’m no longer talking about something which is
the job of the great medical profession. Some may say that
this is now a “political discussion”. Some will agree : ‘‘intellectual nodding”. Again to Somra. I talked to him on this
point. Somra knows the primary cause of diarrhoea very
well, the question is how to treat it. Let all Somras meet and
discuss it. We doctors don’t know how to treat diarrhoea.

Published by M. Ganguli, C/o Bimalendu Das, P.O. Jag-.
dishpur, Via Madhupur (S.P. 815353 Bihar. Printed at Omi
Press, 75 Pataldanga Street, Calcuttar700 009.
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