Health for the Millions, Vol. 9, No. 5-6, Oct. - Dec. 1983.pdf
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Health Association of
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OCT.-DEC. 1983
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COMMUNITY HEALTH CELL
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326, V Main, I Block
Koramangala
Bangalore-560034
India
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HEALTH FOR THE MILLIONS
Vol. IX No. 5 -6, Oct. Dec.1983
A Solution in the Hands of the People
•* r
• V,
In this double issue
We all agree that basic health care is the right of every Indian
whether rich or poor. It is also generally accepted that priorities in health
care should reflect the problems of the most vulnerable populations.
1 The Magnitude of the Tragedy
Yet, how we treat the deprived sections of society, especially our
women and children, is an indicator of our development as a society; and
8 The Treatment of Diarrhoea
the 1.5 million children who die every year of diarrhoea are a tragic
20 The Dangers of Anti-Diarrhoeals : symbol of the inefficacy of our health care system, our passivity and
apathy, our injustice and our cruelty.
33 Diarrhoea and Malnutrition
For the 370 million Indians who earn a mere Rs 65 per month, the
38 Alternatives in Diarrhoea Care
provision of just the basic necessities of life—adequate food, clean drinking
water, sanitary living conditions—would eliminate a majority of their
42 Traditional Home Remedies
health problems, more effectively than all the drugs, doctors and dis
pensaries put together.
45 Programmes in Diarrhoeal
Disease Control
Where rational diarrhoea care is concerned. Oral Rehydration
50 Controversies in ORT
Therapy is considered the biggest medical revolution' of the century.
Effective communication and sharing of this know-how with people,
56 Summary of ICORT Proceedings
ensuring its acceptance as a preferred mode of diarrhoea treatment will
happen only if we are convinced about it ourselves. The importance of the
60 VHAI's role in Diarrhoea Care
role of school teachers, social workers, development workers, activist
63 Book Review
groups, women's groups, trade unions, parentsand older children in health
education and health care is being increasingly recognised—especially
where simple, low cost, medically sound ORT is concerned.
I
—------------------------------------------------- I
Successful treatment with ORT not merely demystifies diarrhoea
Editor
: S. Srinivasan
care, it gives the people a sense of control over their own lives and the
lives of their children, so often lost in needless diarrhoea deaths. For
Executive Editor : Augustine J.
knowledge tint gives a sense of power to the people in their own capa
Veliath
bilities and in their capacity to change the existing situation is priceless.
Production
: Alex J. Dass
ORT is more than a salt sugar mixture for diarrhoea care, it is an
important tool, a ' simple solution in the hands of the people" which can
News & Events : Purabi Pandey
challenge the medical establishment, and initiate a meaningful change in
Assistance
: P. George
the health care system a change towards social justice in all spheres of
life, a system which does not allow needless death or disease, physical
Circulation
: L. K. Murthy
or social.
3 What is Diarrhoea ?
Mira Shiva & Aspi Mistry
Owned and published by the
Voluntary Health Association of
India, C-14, Community Centre, ■
Safdarjung Development
Area, This double issue cf HfM has been put together by Dr. Mira Shiva and
New Delhi-110016, and printed Aspi Mistry. VHAI staff. The Editor thanks them for this diarrhoea
dialogue. Ed. HfM.
at Printsman New Delhi-110005.
The Magnitude of the Tragedy
On May 10, 1979, a DC-10 crashed in Chicago. News cove
rage was intense throughout the wo rid. During the same hour
six times as many children under 5 years of age died of
diarrhoea in the developing world. Imagine the publicity if a
DC-10 crashed every 10 minutes, 24 hours a day, 365 days a
year; yet an equivalent number of children die each year of
largely preventable diarrhoea, without public notice.
No. 17 July 15, 1983
World Development Forum
Diarrhoea is by far the major killer in the developing
world. It has been estimated that annually there are
over 1400 million episodes of diarrhoea in children
under 5 years of age in Africa, Asia and Latin America.
This results in five to eighteen million childhood
deaths per year. In other words, somewhere in the
world EVERY SIX SECONDS A CHILD DIES OF
DIARRHOEA.1 One of every ten children born in
developing countries dies of diarrhoea before reaching
the age of 5.2 Yet the greater tragedy behind this fact,
is that all or most of these deaths are preventable—
not by sophisticated or expensive means—but simple
and cheap home remedies that any child can learn
and use.
When India became a signatory to the Alma Ata
Charter, we were committed to giving priority to the
primary health care needs of our people. Inspite of the
advances that have been made and the prolific growth
of the medical establishment in the urban centres,
with its hospitals, drug companies and super-special
ised personnel—in India alone, 1.5 million children
die annually because of diarrhoea.
In Indonesia, 40% of the population develops
diarrhoea at least once a year; 75% of these are under
the age of 5; 40% of deaths in children under 3 years
are caused by or follow diarrhoea.
When one considers, in addition, that more than
one third of the beds in developing countries are occu
pied by patients with diarrhoea, who may have receiv
ed expensive antibiotics and intra-venous fluids, it is
clear that the disease also has enormous immediate
economic consequences.
"The tremendous human and social costs complete
the tragic picture: Repeated attacks of the disease
lead to stunting malnutrition. Malnutrition leads to
increased susceptibility to infections.
"This vicious circle negatively affects the quality of
the child's life and leads to : retarded growth, missed
learning opportunity, and weakened nutritional status.
The frequency, in some developing countries, of
diarrhoeal attacks is as high as once a month during a
child's second year of life.
In rural Punjab in the early 1970's children under 4
averaged 41 episodes of diarrhoea per 100 children
per month. In the hot, dry season about 60 episodes
per month were recorded. In an average village of
110 children, 18 suffer from diarrhoea on anyone
day.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
1
The Magnitude of the Tragedy
For society, the implication is an increased load on
health delivery systems and budgets, lowered quality
of life, disincentives to family planning programmes
besides the incalculable premature loss of young
lives."3
Is Diarrhoea Only a Medical Problem ?
A few months ago, community health workers,
members of the medical profession, community orga
nisers and leaders met in Washington for an Inter
national Conference on Oral Rehydration Therapy
(ICORT). In reply to the above question, we need only
quote from the address of Dr. Hafdan Mahler, Director
General of WHO, delivered on this occasion :
"It—(diarrhoeal disease)...is a symbol of under
development, and a prominent factor in the poverty
equilibrium. By that I mean the pernicious combination
of unemployment or under-development, scarcity of
material goods, low level of education, primitive hous
ing, poor sanitation, malnutrition, affliction by disease,
and social apathy.
"'The lasting answer to that poverty equilibrium
lies in the genuine human development of the people
$ trapped in it.
"Social and economic progress cannot take place
when infants die in their masses from diarrhoea, 4 to
5 million per year, 1 death every 5 to 10 seconds;
when children are too enfeebled by malnutrition and
disease to derive the full benefit of school education;
when adults are so riddled with disease that they are
too weak to realise their economic and intellectual
capacities, and when they cling to the tenuous secu
rity of producing more children so that some will
survive and sustain them in their old age.3
"High birth rates and high infant mortality rates
resulting from diarrhoea, acute respiratory infections
and other killing infectious diseases, are surely an
extremely primitive and inefficient way of arriving at a
so-called demographic balance. I say 'so-called', be
cause a state of affairs that saps human energy and
leads to further impoverishment and dependency can
hardly be called a balance. So all who are interested
in the demographic future of this world must surely
devote their energies to changing this indecent state
of affairs."
We need only add that in this process the com
munity health worker and the social activist hold the
key to the future.
References
From "State of the Worlds Children—82*83", quoted
James Grant, Director General. UNICEF.
2. Population Report Series Nov.-Dec. '80.
3. "Diarrhoea Management—a Social Priority”—UNICEF.
1.
by
HEALTH I OR THE MILLIONS OCT./deC. 1983
What is Diarrhoea ?
The person with diarrhoea is like a pot of salt water with a
hole in the bottom. A dead patient is like an empty pot. It is
most important to keep the pot full.
Primary Level Guide, WHO
In a very simple language, when a person has three
or more loose or watery stools, he has diarrhoea. If
mucus and blood can be seen in the stools, he has
dysentery. Diarrhoea can be mild or serious. It can be
acute (sudden and severe) or chronic (lasting many
days).
Diarrhoea is more common and more dangerous in
young children, especially between 6 months to 2
years, and especially in those who are poorly nourish
ed. About 60-70% of the children who die from
diarrhoea die because they do not have enough water
left in their bodies. This lack of water is called dehy
dration. This loss of water is accompanied by loss of
important salts like sodium (Na+) and potasium (K+)
bicarbonate (HCO3“) and the balance of salts in the
body fluids (electroylte balance) is disturbed. People
of any age can become dehydrated, but dehydration
develops more quickly and is most dangerous in small
children, since small children due to their greater
surface area in relation to weight and higher meta
bolic rate require
times more fluids per kg than
adults.
Any child with watery diarrhoea is in danger of
dehydration.
On a normal day, 7 to 9 litres of fluid is poured as
secretions into the alimentary canal. Most of it is re
absorbed. Only 100-200 ml. is secreted.
Diarrhoea results if there is increased secretion or
decreased absorption.
Main Causes of Diarrhoea
Poor nutrition. This weakens the child and
makes the diarrhoea from other causes
more frequent and worse
Lactose Intolerance. Inability to digest milk
(mainly in severely malnourished children
and some adults)
Virus infection or Intestinal flu'
Babies having difficulty in digesting new
foods
An effection of the gut caused by bacterias,
amoebas, giardia
Allergies to certain foods; babies' allergy
to cow or other milk.
Worm infections
Laxatives, purges, certain poisons
Infections outside the gut : ear, tonsils,
measles, urinary
Side effects of certain drugs such as
ampicillin, tetracycline
Food poisoning
Overeating unripe fruit, spicy heavy
greasy foods.
HEALTH FOR THE MILLIONS OCT./DEC. 1983
3
The table which follows is "A Clinician's Guide to Aetiology" adapted from Diarrhoea Dialogue, issue 7,
November 1981. (Diarrhoea Dialogue is produced quarterly by AHRTAG at 85 Marylebone High Street,
London W1M3DE). Where it is not possible to make microbiological examinations, we hope it shall prove
useful in identifying, on clinical grounds, the common agents of diarrhoea. It is greatly simplified. For example,
some agents produce a variety of clinical features. Only agents of major importance world-wide have been
included. In certain areas, at certain times, the picture may be quite different.
Try and find out what the important causes of diarrhoea are in your area. Caution: There are a number
of other conditions associated with diarrhoea such as infections outside the gut (e.g. measles and malaria,
malnutrition, food intolerance etc.). Remember to look for these and give specific treatment where appropriate.
Associated Clinical Features
Complaint
Common
* Vomiting
Others
* Severe dehydra
tion in some
* Fever
Type of stool
♦ Clear
* Copious
Incubation
Period
24-72
hours
Transmission
* Foecal
Epidemiological Features OrganismslIncidence First Line Treatment
* Infants and young
children
* Oral
* Common world-wide
in all socio-economic
groups
* Odourless
* Watery
Rotavirus—50%
of all diarrhoeas
in kids—10-20%
generally
* Rehydration
therapy
Enterotoxigenic
Escherichiacoli
(ETEC)-25% of
all diarrhoeas
* Rehydration
therapy
♦ Peak in colder seasons
in temperate climates
ACUTE WATERY
DIARRHOEA
The stool takes
the shape of the
container
* Nausea
* Fever
* Loose
* Vomiting
* Malaise
* Greenish
* Abdominal pain
* Severe
dehydration
* Foul-smelling
* Nausea
* Malaise
(Tiredness)
* Acute febrile
genteritis
6-72
hours
* Food-borne
* Water-borne
* Infants and young
children in developing
countries
* Travellers diarrhoea
in adults
8-36
hours
* Vomiting
* Foul-smelling
* Fever
* Slimy mucus
♦ Food-borne
from animal
products.
♦ multiple
antibiotic resist
common
* Children
* Common world-wide
* Food-borne outbreaks
(animal products)
♦ Rehydration
Non-typhoid
therapy
Salmonellae
10% of diarrhoeas
in developing
countries
♦ Chills
* Warmer seasons
* Abdominal pain
* Abdominal pain
* Chills
* Fever
* Blood 8 Pus in
the stools
* Malaise
3-5
days
* 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
7
1
Associated Clinical Features
Complaint
Common
* Vomiting
Others
Type of Stool
* Severe
dehydration
* Copious watery
stools
* Circulatory
collapse, 'shock'
* 'Rice-water'
type
Incubation
Period
1-3
days
* Abdominal pain
i
ACUTE
!
WATERY
DIARRHOEA
(contd.)
Transmission
* Water-borne
Epidemiological Features Organismshncideiice First Line Treatment
♦ Children in endemic
areas
♦ Food-borne
♦ Adults in newly
affected areas
* Rehydration
Vibrio cholera
therapy
5-10% of
hospitalised cases
* Tetracycline
in non-endemic
areas
* Commonly found
associated with melas,
fairs, escosanal pilgrims
gatherings
* Nausea
* Fever
♦ Nursery outbreaks in
developed countries
6-72
hours
* Vomiting
Enteropathogenic
Escherichia coli
(EPEC)
• Rehydration
therapy
* Uncertain in developing
countries
DYSENTERY
* Fever
* Malaise
* Greenish, loose
The stool is soft
and watery with
blood and/or with
mucus
* Abdominal pain
* Vomiting
* Later blood,
mucus
* Urgency to
defecate
36-72
hours
* Person to person * Children
• Less often by
food and water
* Malnutrition
* Without much
smell
* Institutions
* Painful spasm on
defacation
1
!
PROLONGED
DIARRHOEA (OR
DYSENTERY)
♦ Abdominal
discomfort
* Warmer seasons
♦ Bulky, foul
smelling
2-6
weeks
* From stools into
food and water
For at least 7
days, stools have
been more
frequent or of
softer consistency
(with or without
blood and mucus)
* Abdominal
distension
* Anorexia
* Yellow, bad
smelling
1-3
weeks
* Nausea
* Flatulence
* All age groups
* Metronidazole
* Metronidazole
* Food
* Young children
Giardia
♦ Water
* Some travellers
lamblia
* Frothy, bubbles
* Poor hygiene
* Malabsorption
* Frothy stools
Entamoeba
histolytica
* World-wide
distribution
♦ Blood, mucus
|
• Poor hygiene
Shigellae—5% of * Rehydration
therapy
acute diarrhoeas
in children
* Ampicillin or
under five
Trimethoprim
Sulfamethoxazole
* Without blood/
mucus
• Can be identified on examination of the stools with a light microscope. Blood and pus
from Shigollao and Compylobacter can also be identified.
* World-wide
distribution
Giardiasis can
lead to malab
sorption of
fat soluble
vitamins like
Vit A—replace
ment of vit. A
Produced in collaboration with the Ross Institute of the London School of Hygiene
and Tropical Medicine and The Save the Children Fund.
What is Diarrhoea ?
While it is necessary to identify the specific causative agent of the diarrhoea, if should be borne in mind
that these agents act within the intestinal tract in somewhat different ways:
Salmonella and Shigallae
Enterotoxigenic
E. Coli (ETEC) and
V. Cholera
produce entero toxin which binds
itself to the guts epithelia cells
(cell walls) and leads to loss of
fluid in the gut.
act inside the epithileal cells of
ileum and colon and hence a lot
of fluid is secreted into the
lumen of the gut.
Lumen of the gut
The increased secretion and decreased absorption leads, if unchecked, to dehydration.
Thus, besides identifying the specific organism, for a complete understanding of the diarrhoea, if is abso
lutely essential to make an assessment of dehydration and fluid deficit, as a means to proper management.
A child with
diarrhoea is like
a pot with a large
hole.
6
Treat her by filling
up the pot faster
than the water flows
out.
Prevent diarrhoea by
making the pot strong.
Give the child plenty
of food.
Ifjshe gets diarrhoea
again, start treatment
with salt-sugar water.
This will prevent her
from becoming
dehydrated.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
What is Diarrhoea ?
Assessment of Dehydration And Fluid Deficit*
Severe Dehydration
Mild Dehydration
Moderate Dehydration
Infants, young children
Thirsty, alert, restless
Thirsty, restless or
lethargic, but irritable
when touched
Drowsy, limp, cold
comatose
Older children, adults
Thirsty, alert restless
Thirsty, alert, giddiness
with postural changes
Apprehensive, cold,
sweaty wrinkled skin of
fingers, muscle cramps.
Radical pulse
Normal rate and volume
Rapid and weak
Rapid, feeble,
sometimes unpalpable
Systolic b.p.
Normal
Normal-low
May be unrecordable
Respiration
Normal
Deep, may be rapid
Deep and rapid
Anterior fontanelle
Normal
Sunken
Very sunken
Skin elasticity
Retracts immediately
Retracts slowly
Retracts very slowly
Eyes
Normal
Sunken
Deeply sunken
Mucous membranes
Moist
Dry
Very dry
Urine flow
Normal
Reduced amount, dark
None passed for
several hours, bladder
empty
Percent body weight loss
4-5%
6-9%
10% or more
Estimated fluid deficit
40-51 ml/kg
60-90 ml/kg
100-110 ml/kg
Signs and Symptoms
General appearance :
* Source : WHO Manual for Trainers : Control of Diarrhoeal Disease.
NEWSBITS ON DIARRHOEA
Dr. William Greenough, head of the International
Centre for Diarrhoeal Disease Research at Bangladesh
cited a recent incident where a child was hospitalised
in New York for diarrhoea and his parents ended up
paying 2500 dollars for treatment that could have
barely cost a few dollars.
—Patriot 19-6-83
BUILDING ON PEOPLE’S
TRADITIONS AND BELIEFS
Indian scientists have
achieved a break
through by reducing heavily the rate of child morta
lity from diarrhoeal diseases by introducing oral
administration of Glucose salt fluid to combat dehy
dration. The rate of mortality has now gone down
from 25 to 0.5% according to sample studies carried
out in some of the prominent hospitals in the country.
—Patriot 7-7-83
HEALTH FOR THE MILLIONS OCT./DEC. 1983
7
The Treatment of Diarrhoea
For most cases of diarrhoea no medicine is needed, if the
diarrhoea is severe, the biggest danger is dehydration, if the
diarrhoea lasts a long time, the biggest danger is malnutrition.
So the most important part of treatment has to do with
giving enough liquids and good food.
—David Werner
Where there is no Doctor
STEP 1 : Assessing the degree of dehydration
• Decide whether dehydration is mild, moderate or severe.
9 Look for other important signs : blood or mucus in the stool, fever, enlarged splean, vomiting,
unconsciousness or convulsions, difficult, fast or deep breathing, nutritional status, any evidence
of infection or electrolyte imbalance.
STEP 2 :
Rehydration
• Give back the water and salts already lost in the diarrhoea stools.
O For severe dehydration, this replacement should be completed within 6 hours.
STEP 3: Sustenance
• Continue to replace the losses of water and salts as long as the diarrhoea continues so dehy
dration does not return.
• Start feeding the child the usual diet such as breast milk, or cereals and other weaning foods.
• Treat other infections and complications, using drugs only when needed.
STEP 4: Cure
• Check for signs of malnutrition. Follow up to see that nutrition is improved.
• Teach the mother how to do this.
• In special cases, specific precautions need to be taken, such as eye damage due to Vitamin A
deficiency, especially in deficiency prone areas. Since inadequate intake and absorption of vitamins
takes place in chronic diarrhoeas.
The Treatment of Diarrhoea
STEP 1
In the chart on pages 4 & 5 we have already seen the detailed signs of mild moderate and severe
dehydration. Yet all these signs may not always be observable. To refresh the memory, the diagram below,
can be used as an aid :
DIARRHOEA
I
THIRSTY. ALERT
SKIN ELASTICITY MAY
BE REDUCED
3
EYES AND FONTANELLE
MAY BE SLIGHTLY
SUNKEN
4
RADIAL PULSE NORMAL
5
URINE FLOW NORMAL
2
TOO WEAK TO DRINK.
OAZEO OR UNCONSCIOUS
2 SKIN ELASTICITY POOR
3. EYES DRY. EYES ANO
FONTANELLE SUNKEN
4 RADIAL PULSE WEAK
OR ABSENT
5 URINE FLOW REDUCED
OR ABSENT
Source : Primary Level Guide1
WHO Geneva 1976
STEP 2
Having determined whether the patient is suffering from mild or severe dehydration, the Oral Rehy
dration Therapy (ORT), must begin immediately. Before we go into the actual preparation and administration
of the Oral Rehydration Solution (ORS), and examine the alternatives available, the following two charts will
give us a bird's eye view of the place of ORT in diarrhoea management. They can be used as practical aids in
the diagnosis and treatment:
Mild dehydration
• GSS= glucose-salt solution
Source : Primary Level Guide WHO Geneva 1976
HEALTH FOR THE MILLIONS OCT./dEC. 1983
9
The Treatment of Diarrhoea
Severe dehydration
Source : Primary. Level Guide WHO Geneva 1976
* GSS=glucose-salt solution
The charts above give broad indications when
oral G.S.S. (Glucose-salt solution i.e. ORS) should
be given and when it is necessary to resort to intra
venous therapy. Before we proceed to the methods
of administering ORS, it is necessary to clearly define
those extreme and serious situations in which I.V.
therapy is essential:2
1. A patient with severe dehydration looses more
than 10% weight and shows signs of shock.
2. In patients unable to drink because of stupor,
fatigue or coma, naso-gastric feeding should
be given using an appropriate nasogastric tube.
3.
4.
5.
6.
7.
Those with prolonged oligemia or anuria i.e.
stoppage or severe decrease of urine flow
(more than the amount that can be explained
by dehydration.)
Those with severe and sustained vomiting.
Those with very severe diarrhoea who lose
more fluids than they can absorb, i.e., adults
losing more than 800 ml. of stools per hour.
In premature infants and babies less than one
month old.
Those with serious glucose malabsorption
(about 3% of all patients).
Swedish boycott hits C-G's sales
According to a report published in the Swedish newspaper, Dagens Nyheter, earlier this year, the
boycott by Swedish doctors of Ciba-Geigy products has had a considerable impact (see Scrip No 641, p. 8).
The boycott, which started in 1977, was in protest against the company's continuing sale of Entero-Vioform
and Mexaform (clioquinol) in many countries: it now also involves Swedish veterinary surgeons.
According to the Swedish report, between 1976 and 1980 sales of Ciba-Geigy's medicinal products
for which duplicates were available from other companies fell by 38.5%; sales of products for which no sub
stitute existed rose by 61.2%; and sales of products which could be replaced by other companies: although
they were not identical, fell by 12.2%. The Swiss concern's share of the Swedish pharmaceutical market fell,
between 1 976 and 1980, decreasing from 4.31% to 3.21%; this corresponded to a loss of SKr 70 million
(S 14 million) over the four-year period. Since the veterinary surgeons joined the boycott, the sales of readily
replaceable veterinary products have fallen by 22.5%; preparations that are difficult to replace have, however,
retained their market share.
A Ciba-Geigy spokesman commenting on the figures is reported to have expressed the view that the
boycott accounted for only a small part of the fall in turnover. He is reported to have said that the result was
in part due to "reduced promotional efforts for preparations of doubtful efficacy". Acco:ding to the company,
between 1976 and 1980 turnover increased from SKr 69 million to SKr 77 million. If the market share had
remained at the 1976 level, ths 1980 turnover would have been approximately SKr 100 million.
10
HEALTH FOR THE MILLIONS OCT./dEC. 1983
Tr.e Treatment of Diarrhoea
A Comparison of intravenous fluid and oral rehydration therapy.3
Ora! Rehydration Therapy (ORT)
Intravenous Therapy
Applicable in all cases requiring rehydration.
Applicable in all cases except where shock or severe
vomiting interfere (0-5%.)
Preventive use not feasible
Easily administered in every case of diarrhoea.
begun early may prevent dehydration.
Requires fixed medical care facility
Can be prepared
home.
Supplies are cumbersome to deliver to the rural areas.
Packets of OR salts are easily distributed. Sugar and
salt are available in most homes.
Administration requires well trained personnel.
If
and administered in village and
Can be prepared and distributed by minimally trained
village workers (prepared by family members)
A narrow range of body tolerance for variations in fluid
composition.
A broader tolerance range, but care is still needed in
mixing the ingredients.
Monitoring is required to prevent over-hydration.
During the early stage of diarrhoea the satisfaction of
thirst usually prevents over-hydration.
Requires sterile preparation and equipment.
Household utensils can be used to mix the
ingredients.
Expensive
Inexpensive.
Trauma and chance of
needles.
infection from intravenous
Largely, the mother is excluded from caring for the
child.________ ____________
There is possible risk in using contaminated water.
Mother is involved in the care of the child.
Signs of dehydration appear slowly
Normal
I
Moderare dehydration
1
I
Severe dehydration
Diarrhoea Stools
In all except the most severe and extreme cases,
listed on Page 10), and especially if rehydration is
started immadiately (at the outset of the diarrhoea
HEALTH FOR THE MILLIONS OCT./DEC. 1983
and before all the clinical signs of dehydration appear
—see graph above), oral rehydration therapy has
been found to be the most effective and convenient.
11
The Treatment of Diarrhoea
Preparing the ORS
The oral rehydration solution is basically a mixture
of sodium and potassium salts, sugar and water,
mixed in definite proportions. It can be made at home
by mixing the ingredients in the correct proportions,
but it is also available in pre-packaged packets of salt
which have only to be dissolved in water. In the
absence of some of the ingredients ideally required,
it can also be made with alternatives, or even omitting
certain salts altogether and supplementing these
through other foods and drinks available easily. The
following are some of the possibilities:
ORS FORMULA (Using a spoon set)
Component
weight
Appropriate domestic weight
3.5 gm
1 level teaspoon
2.5 gm
| teaspoon
HCo3 — 30
1.5 gm
| teaspoon
K* 20 Cl—80
Milh mol / litre
Na Cl
|
(Sodium Chloride,
Common Salt)
Na HCo3
(Sodium bicarbonate)
“Soda - bicarb”
backing soda
KCI
(Potassium Chloride)
Na* 90
8 level teaspoon
!
1
Sucrose (Sugar)
•Zb*.
Water
12
, ..
,x
1 litre = (1000 ml.)
glucose 110
T’tITL
Keep a correctly marked container, if you do not have a
a ,
measuring flask.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
The Treatmsnt of Diarrhoea
Home made formula (No spoons)
1
While preparing ORS
Do not keep the mixture for more than 24 hours. Make fresh mixture daily. If necessary, make smaller
quantities using the formula proportiontely for one glass.
All the signs and symptoms of dehydration will not always be present in one patient. If just
two or three are observed they should be used as indicators to determine whether dehydration
is mild, moderate, or severe.
Subscribe Now
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Mary K. McNabb, BA CRNA
Coordinator
VHAI Nurse Anaesthesia Programme
Bethesda Hospital
P.O. Ambur
North Arcot Dt
Tamilnadu-635802
health for the millions oct./dec. 1983
Wanted urgently
Wanted urgently a Nurse Anaesthetist (Male or
female) for 220 bed hospital in rural Tamilnadu. Ade
quate salary, accommodation (for single or family)
provided. Kindly contact the Medical Superintendent
St. Thomas Hospital and Leprosy Centre, Chettupattu
606801 N A. Dt., Tamilnadu.
13
The Treatment of Diarrhoea
Adaptations of the Formula
1. Sodium Chloride (NaCI)/Salt—This is an
essential ingredient and its replacement is very vital
in managing dehydration. There are arguments against
using a high sodium formula (3.5 gms. NaCI, 1 tea
spoon) as in the WHO recommendation, because of
the human error involved in preparation of boxed
ORS. (See box on SODIUM CONCENTRATIONS for
details). For a greater margin of safety instead of
.J teaspoon, i teaspoon salt may be used especially for
smaller children.
mula is being used (i teaspoon NaCI), NaHCO3 may
be substituted by another i teaspoon NaCI. Sodium
acetate, citrate, lactate are easier to package and pro
duce in form and have a longer shelf life. In home
made solutions baking soda is used.
2. Sodium Bicarbonate (NaHCO3)—prevents
or reverses acidiocis. It improves the appetite and leads
to cessation of vomiting. While it is recommended for
severe acute diarrhoea, for routine therapy, for mild or
early diarrhoeas, the addition of bicarbonate is not
considered absolutely necessary. If low sodium for-
4. Potasium Chloride (KCI)—Potassium losses
in diarrhoea stools of children tend to be higher than
in adults. Replacement of potassium losses is impor
tant. If KCI is not available, selected potasium rich
foods are required to supplement oral rehydration with
a sugar and salt solution.4
3. Sucrose—Sucrose is ordinary white sugar,
used at home. For a detailed discussion on the role of
Sugar see box that follows "Glucose or Sucrose?"
Incidentally, 8 level teaspoons=2 level tablespoons.
Amount required per 24 hours
Food
Small
Plantain (raw)
Coconut water
Lemon juice (raw)
Organgl juice (raw)
Papaya mashed
Tomato raw
ripe
281 gms.
1i cups
Banana (raw) mashed
whole (without skin) :
Large
Medium
...
2 bananas
2j bananas
3 bananas
1 plantain
3 cups
3 cups
2 cups
2 cups
4 tomatoes
§ tomatoes
...
256 gms.
261 gms.
270 gms.
263 gms.
720 gms.
732 gms.
496 gms.
460 gms.
467 gms.
5. Water—The person making the ORS should
have a container previously marked to measure 1 litre.
Most cold drink bottles have their capacity marked
on them (e.g. average sized glass=200 ml.; Thums
Up or Double seven = 200 ml. Thus 5 bottles of
Thums Up = 1 litre. =2 milk bottles). Most liquor
bottles have their volumes marked on the label. Stan
dard sized milkcans or anyother everyday item can be
used to mark up a container.
Insistence on boiling the water for ORS has often
needlessly delayed and often inhibited mothers from
giving the urgently needed ORS. Hence the emphasis
is being put on early fluids rather than on use of
boiled water. With the existing fuel shortages in the
field it would have been an unreasonable proposal
any way.
Boiling of Water : A comparative study con
ducted in Gambia-found that it made no difference
to the incidence or duration of diarrhoea whether the
water used for ORS was clean or contaminated.
BOILING IS NOT ESSENTIAL. In any case, the ORS
should NOT be boiled after mixing. If is sufficient to
use as clean wafer as possible.
The mechanism by which ORT works, and the role
which the balance between sodium, glucose and water
plays in this process, make it clear why very definite
proportions have to be maintained when preparing the
ORS. To elaborate this further, the following three
sections deal with sodium, glucose and potassium in
some detail.
14
See the centrespread for other methods of
measuring the ingredients for the ORS.
HEALTH FOR THE MILLIONS OCT./DEC. 1983
The Trearment of Diarrhoea
How does ORT work ?
Normal Small Intestine
Intake: *lsotonic salt
Isotonic salt 4- water
Result : Normal absorption of Na+ and H20
Intake : Nothing
Result : Dehydration develops
In diarrhoea, even if
nothing is taken by
month, fluid is still
lost into the bowel
from bowel walls.
Enhanced absorption of Na4" and H20
Isotonic salt
Dehydration worsens
If only salt water is given, diarr
hoea worsens and extra fluids are
lost leading to further dehydration.
Isotonic salt 8- glucose
Dehydration is maintained or
corrected
If glucose is added to salt and
water, absorption of Hu ids and salt
is increased by 2500%. Even
though salt and water are still lost,
there is an overall gain.
*lsotonic Concentration—same as in blood.
Source : Oral Fluids—A simple weapon against dehydration in Diarrhoea —How it works and how to
use it. N.T. Pierce and N. Hlrschhorn. WHO Chronicle 31-/87-93 (1977).
Thousands of Congratulations
Dear Editor,
Thousands of congratulations to you for publishing the beautiful issue of Health
for the Millions on the topic of Health and Meaning of Life. Each and every issue
of the magazine is full of new information and treasure of knowledge, which widens
the horizon of understanding of the human life.
I express my deep gratitude and high appreciation for publishing the interview
of Sister P.M. on page 8 of June issue. Sister P.M. has shown an ideal great spirit
of courage, boldness, heroism, sacrifice, service and love for truth and
humanity. The institutional structure of religion, society, politics, economic,
organisation, education etc. , is suppresssng everywhere the demand of justice,
freedom of the development of the individual, aspiration for equality, harmony
and prosperity, and manifestation of the divinity of human souls on surface of
the material life. I send my sabatations to Sr. P.M. for following her inner
voice of truth and heroic service of the common people. Kindly convey my feelings
to her, because I do not know her address.
With my best regards,
Koraput, Orissa.
Sep. 29, 1983
health for the millions oct./dec. 1983
Yours etc.
S.C. Shrivastava
15
The Treatment of Diarrhoea
Glucose or Sucrose
In mild or moderate diarrhoeas, both sugars are
equivalent. Sucrose needs an enzyme to break it
down to glucose, which is the active substance, hence
twice the amount of sucrose is required if it is to act
as a substitute for glucose in the ORS. i.e. 20 gms
glucose=40 gms sucrose.
Sugar is needed to help in absorption of electro
lytes to replace the large amount lost in stools and to
provide energy.
giving salt-gur rehydration therapy—acidosis in 20%
cases was not corrected. For moderate to severe
diarrhoea cases glucose is preferable to sucrose and
specially to jaggery.
''More nutritious substracts, e.g. casein hydralysate,
lysin absorbed by multiple absoriptive non-competitive
pathways afford the following benefits :
1.
Increase of the quantity and rate of fluid elect
rolyte absorption.
2.
Increased nutrient absorption
energy and amino acids.
3.
Decrease stool volume.
4.
Faster recovery, 7 short cell renewal time, because
of ready availability of nutrients, better absorption
of ORT.
5.
—Glucose is more costly and less easily available.
Better digestion of diet because of continued
enzyme induction. Cereals, legumes and other
locally available simple foods may become in
proper quantities,^ basis of combined fluid protein
energy and therapy".5
Replacement of sugar by gur/jaggery is fine, except
in cases of severe dehydration or where acidosis is
suspected. Studies show that even after 48 hours of
It seems after all that dilute dal wafer (specially
of moong dal) for diarrhoea is not a bad idea, specially
if a little sugar and salt is added.
However very high concentrations of sugar can
cause osmotic diarrhoea and exacerbate existing
diarrhoea. ORT provides only 8 K cal/100 cc of
energy.
—Glucose is more hygroscopic and therefore has
to be packaged in plastics, polythene or foil
packaging.
—Volume of vomiting or proportion of infants
vomiting severely may be greater with sucrose.
Sodium Concentrations
While the 90 mg/lit. solution as recommended by
WHO is effective for all diarrhoeas, and severe secre
tary diarrhoea like cholera may require even higher
percentages, there are strong arguments against the
high sodium formula :
1.
Since sodium losses vary, hypernatremia i.e. high
blood sodium level may result.
2.
Having a low sodium solution will give a greater
margin of safety, specially in the field where moni
toring and supervision are not always possible.
3.
(a)
Incorrect mixing of ORT, causes of hyper
natremia may be : due to salt overload
(120 ml/lit.)
(b) excessive administration of correctly mixed
ORT
(c) continued administration even after diarrhoea
has stopped, or
16
(b)
providing
both
excessive ingestion of glucose, which worsens
the diarrhoea causing decrease in blood
volume and increase in sodium concentration.
However, transient elevation of serum sodium
occuring with WHO recommended solution is rapidly
corrected when feeding commences. The clinical signs
of hypernatremia are (1) irritability, (2) mental con
fusion, (3) convulsions and twitching (4) irregular
respiration (5) stupor and eventually coma.
On the other hand, there is greater risk of persis
tent hyponatremia with lowering of sodium to
60 mg./lit. with low sodium fluids.
A better margin of safety would be to give sodium
free water independently (1 cup water with 2 cups
ORS) and/or breastfeeding alternatively. Most field
workers and trainers recommend a slightly restrained
use of salt in home based ORS.
HEALTH FOR THE MILLIONS OCT./dEC. 1983-
The Treatment of Diarrhoea
POTASSIUM : K-deficiency already exists in mal
nutrition. This deficit is worsened in acute diarrhoea,
especially infantile diarrhoea leading to acidosis as
extracellular shift of potassium takes places.
muscle weakness, atony (i.e. no bowel sounds),
abdomen bloated, no muscle tone, limbs become limp
and floppy, irregularity of heart, kidney damage,
irregular pulse, decreased urine flow.
Signs of Hypokalemia: Apathy, decreased appe
WHERE KCI IS NOT AVAILABLE, K-RICH FOODS
ARE A MUST
tite (specially in early rehydrated stage, paralytic ileus
Administering the ORS
The volume of ORS to be given will depend on the
weight and age of the child. While an adult will need
at least 3 litres or more per day, the volume for
children should be calculated more carefully.
guide for the direction which the weight curve of a
child should follow from the age of 1 month to 5
years. In most populations the child's weight will be
recorded in the space between these two lines. A
child whose weight falls below the lower curve may
be considered to be malnourished.
In the following diagram, the quantities to be
administered are superimposed on a typical growth
chart for ready reference. The two curves provide a
Forced feeding in large amounts of a very sick and
drowsy child or an infant who is vomiting—can result
in aspiration of oral rehydration fluid or vomitus.
While administering the ORS
1.
Do not give large quantities at one time.
2. Give sips of tne drink every 5 minutes—day and
night until the person begins to pass urine norm
ally and looks rehydrated.
3.
Use a clean cup and spoon.
For babies use a dropper or syringe {without the
needle).
5. If the child is fatigued or drowsy, feed with a
nasogastric tube (recommended rate 15 ml/kg/hour
4.
health for the millions oct./dec. 1683
to 20 ml/kg/hour for more severe cases and when
the child is in shock).
Vomiting is not uncommon during the first one
or two hours. Do not discontinue ORT because
of vomiting. Initially give slowly in small sips.
7. If vomiting persists, I.V. fluid may have to be
given.
6.
8.
Due to gastrocolic reflex, child may pass stools on
taking ORS. Reassure the patient and continue
ORS. Inform the patient that ORS is to prevent
dehydration and not to stop diarrhoea.
17
The Treatment of Diarrhoea
ORT has been well researched and documented.
With cholera and diarrhoea, when treated by experi
enced workers, there was no mortality and the need
for I.V. fluids was reduced by 70-90%. Mortality fell
from 25% to only 3.6% during the cholera epidemic
amongst Bangladesh refugees in the 1971 war. Treat
ment was administered by untrained family members
and half of these deaths occurred before treatment
could be started.
#
STEP 3
Sustenance takes care of :
•
the serious problems that cause or complicate
the dehydration.
•
the replacement of further fluid loss as fast as
it occurs—thus maintaining rehydration.
nutritional rehabiliation.
When rehydration is well under way, it is important
to look for any conditions that might be causing or
complicating the diarrhoea. While the replacement of
further fluid losses as fast as they occur is taken care
of by continued ORT, it is necessary to restore the
patient to his regular diet.
Source: Page—160, "Where There Is No Doctor", David Werner. For more details about tetracycline, see
note on tetracycline in section on "the Dangers of Anti-diarrhoeals."
There is no physiological basis to the common belief
that the bowel should be 'rested' during acute diarrhoea
Wanted Nurse Anaesthestist
An experienced and qualified nurse anesthestist immediately.
Apply with full biodata and copies of certificates to :
Director. St. Thomas Hospital, Chetipuzha, P.O. Changanacherry,
Kottiyam Dist. Kerala 686104.
Pay scale is according to the Kerala Government Gazette notification September 1980.
18
HEALTH FOR THE MILLIONS OCT./DEC. 1983
The Treatment of Diarrhoea
Food for a Person with Diarrhoea
When the person is vomiting or feels too sick to
eat, he should drink :
As soon as the person is able to eat, in addition
to giving the drinks listed at the left, he should
eat a balanced selection of the following foods
or similar ones.
Breastmilk
Teas
Energy Foods :
Body building
Foods :
ripe or cooked
bananas, rice,
ragi, dalia, oatmeal or other
well cooked
grain, fresh
maize (wellcooked and
mashed), potatoes, papaya
curd.
Milk (diluted with
water, whole milk
later)
Eggs (boiled)
Meat (without fat
or grease)
Beans, lentils, dal
peas (well cooked
and mashed)
Fish (well cooked)
Chicken.
Rice water
chicken, meat, egg,
bean soup,
ORS
dal water
.________ __ _____
Do not Eat or Drink
Fatty or greasy foods
most raw fruits,
whole grain
Alcoholic drinks,
any kind of
laxative or purge
Food fried,
spiced and
hotfood
Please also see the section on "Feeding m Diarrhoea" in this issue.
STEP 4
using the protein and energy foods available to her.
The mother should be encouraged to attend the health
centre for immunization and nutrition education.
For A Complete Cure
Nutritional Rehabilitation : Malnutrition following
diarrhoea requires special attention. In order to make
up for the nutritional losses incurred during diarrhoea,
it is recommended that for a period equal to twice the
number of days of the diarrhoea episode, after the
diarrhoea is over, the patient be given one extra meal
every day for at least 1 week or till normal weight is
gained.
For children, a weight chart should be kept and the
mother taught how to improve her child's nutrition
References
1.
Treatment and Prevention of Dehydration in Diarrhoeal Diseases.
—a Guide for Use at the Primary Level. WHO, Geneva.
2.
Oral Fluids- A Simple Weapon against Dehydration in Diarrhoea :
WHO Chronicle. 87-93: 1977.
3.
ORT. p. 36. and Population Reports—Nov. — Dec. 1980.
4.
ORT—Population Report : The table was devised from data
obtained at Hospital Escinela, Legucepalpa, Honduras and
from Adams.
5.
"Diarrhoea and Malnutrition"—Lincoln Chen.
Nurse Anaesthesia
Applications are now being taken for Batch XVII to begin 20th of January 1984 in North India. You may
apply to : Miss Mary K. McNabb, BA CRNA, Coordinator, Bethesda Hospital. Ambur PO 635802, N.A.
Dist. Tamil Nadu.
HEALTH FOR THE MILLIONS OCT./DEC. 1983
19
The Dangers of Anti-Diarrhoeals
Rational Therapeutics may be defined as the know
ledgeable prescribing of the most effective, least
toxic, least costly, easily available drug given in the
right dosage, for the right duration in the right manner
—and of course, for the right problem.
The various other drugs marketed as anti-diarrhoeals and widely used and misused fall within three
broad categories :
* anti-microbial agents
* stool thickening agents
By these criteria the management of diarrhoea in
our country is perhaps the best example of irrational
therapeutics. The painful fact is that this "manage
ment" is confined to prescribing the so-called antidiarrhoeal combinations with questionable therapeutic
effects and often extremely hazardous side-effects.
With the practice of self-prescription and over the
counter purchase becoming more widespread, this
misuse has reached even the remotest areas. Besides
the money losses which affect people who can least
afford such extravagant therapeutics, these misdirected
prescribing efforts further detract from attempts to
focus on the real- problems—prevention of diarrhoea
through environmental controls and correct diarrhoea
care through oral rehydration therapies.
In a situation where prescribing and dispensing of
drugs is a matter of profits, it becomes the responsi
bility of socially conscious health personnel to ensure
that the right drugs are produced and made available
to those who must need them, and that hazardous or
irrational drugs are thrown out of the market. Yet
very often it is the medical respresentatives of the
drug companies and their free attractive "literature"
that from the only source of ongoing medical educa
tion for health personnel. Therefore it is only by
demonstrating some of the myths surrounding the
unquestionable healing properties of all drugs and
demystifying the magic pill that we can hope to
influence more and more people to adopt a healthy
attitude to health problems.
* anti-motility drugs (or gut paralyzers)
Anti-Microbial Agents
Antibiotics have no role in the majority of diarr
hoeas as 50-70% of the diarrhoeas are viral In the
section on "What is Diarrhoea ?" we have already
seen the clinical symptoms of the each type of
diarrhoea and broadly indicated the situations in which
antibiotics are to be used.
The following table is a more detailed exposition
of the correct use of antimicrobials in specific
diarrhoeas. However in general, antibiotics should be
used only:
* When there is clear clinical suggestion of invasive
diarrhoeas (blood in stools and high fever) or
cholera (in cholera endemic areas), or
* When lab results become available and indicate
the need for antibiotic treatment.
* by local irritation
* by super infection with bacteria like staphy
lococci or fungi e.g. Candida.
* by causing psendo-membranous colitis (ampi
cillin) or by causing malabsorption (neomycin)
Ina study byChandrashekaran et al it was found
that 35% of their cases had received one or more
antibiotic prior to hospitalisation.1
Antidiarrhoeals
In the previous section on "The Treatment of
Diarrhoea" we have already examined in some detail
correct management of the disease through Rehydra
tion Therapies,
20
All this in no way means that antibiotics should
not be used; it merely implies that they should be
used judiciously, whenever needed and in adequate
doses tor the correct duration. Below we give some
of the more commonly misused antibiotics.
health for the millions oct./dec. 1983
The Dangers of Anti-Diarrhoeals
Antimicrobials used in the Treatment of Specific Causes of Acute Diarrhoea
Source: WHO/CDD/SER/80.2 Pg. 14.
Cause
Drug(s) of choice1
Cholera2?
Tetracycline
Children—50 mg/kg/day in 4
divided doses x 3 days
Adults 500 mg 4 times a day x3 days
Alternative1
Furazolidone
Children1—5mg/kg/day in 4 divided
doses x 3 days
Adults—100 mg 4 times a day X 3 days
Erythromycin4
Children—30 mg/kg/day in 3 divided
does x 3 days
Adults—250 mg 4 times X day x 3 days
Shigella
dysentery2,
Ampicillion—100 mg/kg/day in
4 divided doses X 5 days
Nalidixic Acid—55 mg/kg/day in 4
divided doses X 5 days (all ages)
Trimethoprim (TMP)—Sulfamethoxazole
(SMX)
Children—TMP 10 mg/kg/day
and SMX 50 mg/kg/day in two divided
doses X 5 days
Tetracycline7—50 mg/kg/day in 4
divided doses x 5 days (all ages)
Adults—TMP 160 mg and SMX
800 mg twice daily x 5 days
In very severe cases:
Dehydroemetine hydrochloride by deep
intramuscular injection, 1-1.5 mg/kg
Adults—750 mg 3 times a day X 5-10 days (maximum 90 mg) for up to 5 days
depending on response (all ages)
Acute
intestinal
amoebiasis
Metronidazole6
Children—30mg/kg/day x 5-10 days
Acute
giardiasis
Metronidazole7
Children—15 mg/kg/day x 5 days
Adults—250 mg 3 times a day x 5 days
1.
Quinacrine
Children—7 mg/kg/day in divided
doses X 5 days
Adults —100 mg 3 times a day x 5 days
All doses given are for oral administration unless otherwise indicated.
2.
Decision on selection of antibiotic for treatment should take into account frequency of resistance to antibiotics in the area.
3.
Antibiotic therapy not essential for successful therapy but shortens duration of illness and excretion or organisms in severe cases.
4.
Other choices include chloramphenicol and trimethoprim-sulfamethoxazole.
5.
Antibiotic therapy especially required in infants with persistent high fever.
6.
Tinidazole and ornidazole can also be used in accordance with the manufacturers' recommendations.
7.
See note on Pediatric Tetracycline below. Better to use alternatives, especially when can be afforded.
Antibiotics when used excessively or unnecessarily, can themselves be the cause of diarrhoea :
HEALTH FOR THE MILLIONS 0CT./DEC. 1983
21
The Dangers of Anti-Diarrhoeals
Paediatric Tetracycline
Children receiving long or short term therapy with
tetracycline may develop brown DISCOLOURATION
OF THE TEETH. The larger the dose of the drug, re
lative to body weight, the more severe is the defor
mity, the deeyer the colour and the more intense the
hypoplasia of enamel. The quantity received is more
important than the duration. Mild darkening of the
permanent teeth occured in 3 to 14 children who
received 5 courses of the drug, whereas 4 to 6 who
received eight courses had moderate darkening of the
enamel.2
The risk of this is highest when the tetracycline is
given to neonates and babies prior to the first denti
tion. If given between the ages of 2 months and 5
years pigmentation of the permanent teeth may
develop.
The earliest characteristics of this defect is yellow
■fluorescence probably due to the formation of a tetra
cycline—calcium orthophosphate complex; with time
this progress to a permanent brown pigment.
Tetracyclines exert a Catabolic Effect perhaps due
to a generalised inhibition of protein synthesis in mam
malian cells".
"Administration of 2.5 to 3 gms. of Chlortetra
cyclines given to under-nourished adults results in
weight loss, increased urinary nitrogen excretion,
negative nitrogen balance, and elevated servum non
protein nitrogen concentration.3
Some effects of antibiotics on nutrition in man,
including studies of the bacterical flora of the faeces.4
In India the majority of children who would receive
tetracycline are malnourished or bordering on malnutri
tion. They would be repeatedly picking up infection
— more often viral but bacterial infections as well.
Additionally, how much of this drug would get pre
scribed by different doctors or consumed anyway, we
don't know.
Tetracyclines are deposited in the skeleton of the
human foetus and young child. A 40% depression of
Bone Growth as determined by the measurements of
fibula, has been demonstrated in premature infants
treated with these agents.5
22
Tetracycline may cause increased intracranial
pressure and tense bulging of the fontanels (pseudo
tumor cerebri) in young infants, even when given in
usual therapeutic doses".6
Increased intracranial pressure presents itself with
severe headache, vomiting, loss of function of certain
cranial nerves, and limbs and if severe, even death.
The figures of the common or rare entity are not
available to us right now.
The ingestion of out dated and degraded tetra
cycline is known to cause Fanconi Syndrome—a
clinical picture characterised by nausea, vomiting,
polyuna (increased passage of urine, polydipsea—
increased thirst, acidosis, protienuria glycosuria and
aminoacidune passage of proteins, glucose and
aminoacids in urine).
Pregnant Women appear to be particularly susceceptible to severe, tetracycline-induced hepatic
damage".7
"Jaundice appears first, and azotemia acidosis and
irreversible shock may follow. Although hepatic fat is
increased during pregnancy, the quantity appears to be
even greater after exposure to a tetracycline.8
Treatment of pregnant patient with tetracyclines
may produce discolouration of teeth in the offspring.
Ingestion of the drug between mid pregnancy to about
4-6 months of post-natal period is dangerous for deci
duous anterior teeth and from 6 months to 5 years of
age for the permanent anterior teeth.9
In Australia, the Drug Evaluation Committee has
recommended the banning of all tetracyclines in pae
diatric formulas. In Belgium, the Philippines, Italy and
the U.S.A., Bangladesh the drug has been banned
from paediatric formulas. In addition, there is the com
pulsory warning: Not to administer in pregnancy and
to children below 8 years.
The International Organisation of Consumers Union
has listed tetracycline as one of 44 problem drugs,
rated as a widespread serious problem.
Paediatric Tetracycline is now banned in India.
Neomycin
Neomycin has no role in the treatmet of diarrhoea.
it can not only cause renal damage but it can also
HEALTH FOR THE MILLIONS OCT./DEC. 1983
The Dangers of Anti-Diarrhoeals
make diarrhoea dehydration and nutritional losses
worse and could interfere with ORT. It has been well
established that neomycin reduces intestinal absorp
tion of sucrose, sodium, pottassium, nitrogen, fat, iron,
lactose, Vit. B12 and xylose.
In a recent study, Mary lan Clements showed that
neomycin can cause diarrhoea in healthy individuals
and prolong it in individuals with E-Coli.
Chloramphenicol-Streptomycin
Chloramphenicol by itself is a less expensive drug
and for this reason is widely prescribed for trivial in
fections and diarrhoea. While it should be used as the
drug of choice for typhoid, its overuse in other situa
tions exposes the patient to a high risk of aplastic
anaemia. Another danger related to its widespread
misuse is the emerging resistance of salmonella to
chloramphenicol. In 1974 in Mexico, 2000 peopl? died
of typhoid which failed to respond to chloramphenicol
because of drug resistance built up through previous
misuse.
Chloramphenicol toxicity is a hypersensitive reac
tion as well as dose dependent.
The chloramphenicol—streptomycin combination
frequently used for diarrhoea (e.g. chlorostrep) is an
extremely irrational combination. There can be no point
in combining a bacteriocidal and bacteriostatic drug
and the combination is banned in many developed
countries and now also in Bangladesh..
In India, the sub committee of the D.C.C. (Drugs
Consultation Committee) had recommended the weed
ing out of all chloramphenicol combinations but the
present notification has banned all of them except
chloramphenicol with streptomycin.
Entero-Vioform (Ciba-Geigy) have been widely used
for prophylaxis and treatment of gastroenteritis, amoebiasis and ' travellers diarrhoea".
The benefits of using clioquinol against diarrhoea
have not been proved. But the dangers have been
clearly compared with the thalidomide catastrophe
in severity.
Clioquinol has caused thousands of cases of SMON
— sub acute myelo optic neuropathy—a condition in
volving continuous pain, paralysis, blindness and in
extreme cases death.
In Japan, cases of SMON reached epidemic pro
portions—affecting an estimated 10,000 to 30,000
people—before the drug was banned there in 1970.
In 1978, after 8 years of litigation over the claims of
Japanese victims of SMON, the Tokyo District Court
reached two decisions —the first of several similar
rulings. The court found first that clioquinol caused
SMON. Secondly, it was found that CIBA-GEIGY
et al were liable, in failing to pass on information
about the dangers of clioquinol. Ina written apology
through the court CIBA GEIGY were -forced to say
"these grievances (of the SMON victims) were all
earnest expressions of their pain, distress, and anger;
appeals were made for redress. They were heart
rendering cries that made us realise anew that SMON
has caused the patients and their families unimagin
able misery.-.In view of the fact that medical products
manufactured and sold by us have been responsible
for the occurrence of this tragedy in Japan, we extend
our apologies, frankly and without reservation, to the
plaintiffs and their families."
Hydrixyquinolines (clioquinol) were introduced into
the Swiss Pharmacopea in 1900 as a topical and anti
septic agent. In the 30's it became a focus of interest
when its potential as an intestinal amoebicide was
investigated. The initial clinical trial of clioquinol was
conducted in the U.S.A, in 1933 and data cited in this
report suggested "'the compound might have a useful
spectrum of actions against other enteropathogenic
protozoa and bacteria." In 1934 the first proprietary
preparation was promoted to the public for treatment
of amoebic dysentery and simple diarrhoea. Since
then, halogenated oxyquinoline derivatives (HOQ)
under such popular brand names as Mexaform and
HEALTH FOR THE MILLIONS OCT./DEC. 1983
23
The Dangers of Anti-Diarrhoeals
How Useful is Clioquinol ?
"The claims for the value of clioquinol in the pre
vention and treatment of that nebulous ragbag "tra
vellers diarrhoea" do not withstand critical exami
nation."—The Lancet 1977.10
"The committee (on Safety of Medicines, UK) has
reviewed the data relating to the efficacy of clioquinol
in the treatment of diarrheoa, and considers, "that
there is inadequate evidence to support this claim"—
Pharmaceutical Journal 1977.11
The drug was excluded from consideration by a
WHO expert committee convened in 1977 to prepare
a model list of "essential drugs" on the grounds that
the risks of treatment out-weighed the potential
benefits.
(Refl WHO 1975 : Selection of Essential Drugs.
Techn. Ref. Series 615, page 14).
The editorial in the Journal of American Medical
Association 10th April 1972, page 273 stated :
"....... in the 40 years that clioquinol has been avail
able only one study which is not entirely convincing,
has shown it to be effective in preventing travellers'
diarrhoea whereas one other prospective study has
shown it to be no more effective than a placebo---"
"Hydroxyquinolines are active only on organisms
present within the intestinal lumen. Used alone, there
fore, they are active only in the absence of significant
tissue invasion—a development that cannot be exclud
ed with certainity even in patients with asymptomatic
amoebiasis".
PDT/DI/78.1 WHO : Drug Information.
Jan-March 1978
According to Dr. P.C. Pandiya of Jaipur, then
President of the Pharmacy Council of India. "The
Indian brand of Mexaform contains 2 more drugs
(besides Iodo chloro hydroxyquinoline the basic drug
—phanquone and oxyphenonuim—and has come to be
used not only for travellers' diarrhoea but diarrhoea of
all descriptions including that due to indigestion".
"The dramatic relief is due to oxyphenonuim which
reduces the spasm of the intestines and bowel move
ments and thus markedly reduces abdominal pain and
discomfort".
24
What is the incidence of SIMON outside Japan ?
According to a Lancet editorial of the 28th May
1977, page 596, "the companies deny that the neuro
logical damage from clioquinol is a serious risk outside
Japan and identical abnormalities of the nervous
system have been reproduced in animals".
According to the Journal of the American Medical
Association : "The absence of epidemics in other
countries does not invalidate the conclusion that clio
quinol is neurotoxic. Clinicians from England, Ausralia,
Switzerland, Sweden, Denmark, the Netherlands, and
the USA, have described patients who developed
neurological symptoms while taking these com
pounds.
The clinical symptoms of these patients were like
the one that characterised SMON".
Journal of the American Medical Association
23rd July, 1973 : Page 296.
According to an international survey on recent
reports concerning intoxications with halogenated
oxyquinolines derivatives—"A survey of the literature
has proved that 86 cases were reported as SMON or
intoxication of halogenated oxyquinoline derivatives
(including suspected cases in 47 articles published
outside Japan from January 1970 to February 1977).
Consumer Action
Although Ciba-Geigy accepted its responsibility in
Japan, it continued to market its preparations in many
countries, especially in the Third World and without
adequate warning to consumers.
In the summer of 1976, Dr Olle Hanson proposed
that all Ciba-Geigy products should be boycotted
in Sweden, in protest of the company's callous policies
in Third World countries. The successful Boycott by
2000 Swedish doctors in which doctors from Norway
and Denmark joined later, caused the company to lose
a third of its market equivalent to a sales loss of 130
biilion Swedish Kroners (nearly Rs 2000, million). As
a result of this action Ciba-Geigy conceded defeat
and agreed to phase out clioquinol preparation from
most countries.
Closer home, Nepal, Pakistan in (1983) and Bangla
desh in (1982) have banned the drug. In India the
HEALTH FOR THE MILLIONS OCT./DEC. 1983
The Dangers of Anti-Diarrhoeals
Hathi Committee observed that though HOQ are sup
posed to be prescription drugs, they can be obtained
in any amount over the counter without prescription,
without adequate warning. In 1977, a special com
mittee of experts was set up to review the use of clio
quinol. The committee had a number of recommenda
tions to make and had suggested studies and follow
up action. It may be recalled that both committees
had functioned at a time when the clioquinol—SMON
story had not yet hit the headlines and the findings of
the International Committee on SMON had not been
made public. Although this is now common knowledge
throughout the world, the stand of the Drugs Controller
of India has been consistently that he has no intention
of banning it in India. In fact in a recent interview
with us, he started with an air of finality that he found
it effective and useful and was used to taking it him
self, even prophylactically I12
Stool Thickening Agents
Some of these are kaolin, pectin, activated char
coal, aluminium hydroxide and bismuth salts.
These drugs do not stop leakage of water and elec
trolytes from the intestinal walls into the lumen. The
artificially thickened stools may produce a false sense
of complacency and hence rehydration is delayed. A
study done by Dupont to see the effect of bismuth
sub-salicylate and placebo in 169 students in Mexico
showed no difference in total weight of stools or stool
water content.13 Spending Rs 1 to 2 per day on pectin.
kaolin preparations to improve the cosmetic appear
ance, of stool, does not appear worthwhile.
Anti Motility Drugs
These drugs include diphenoxylate, opiates, atro
pine alkaloids, loperamide.
They act by reducing tone and segmental activity of
the small intestine, increasing transit time in the bowel.
The decreased gut motility results in statis. Harmful
organisms which are yielded from the gut by peristalsis
continue to harbour. Study has shown that diphenoxy
late Iatropine in experimental shigellosis, not only pro
longed the diarrhoea and systemic symptoms, but also
appeared to contribute to the development of antibiotic
induced diarrhoea and pseudomembranous colitis.14
Stasis resulting from the use of antimotility drugs
have several harmful effects :
1. sequestration or secretion of fluid and in the
gut lumen may manifest as hypovolemia, even
in the absence of overt diarrhoea. A situation
HEALTH FOR THE MILLIONS OCT./DEC. 1983
which makes the clinical assessment very
difficult. That is fluid is lost into the bowel
leading to dehydration and electrolyte loss
even in the absence of obvious diarrhoea.15
2. statistics of fluid in the gut results in abnormal
multiplication of bacterial flora with greater
chances of invasion of bloodstream.
3. the distension of abdomen resulting from para
lytic items may interfere with diaphragm and
cause respiratory difficulty.
Walion et al. have seen cases of severe paralytic coma
and apnea, etc., due to overdosage of diphenoxylate—
side effects resemble morphine poisoning (with which
the molecule of diphenoxylate resembles).
These agents are very dangerous for infants who
have invasive diarrhoea or paralytic illness.
In acute infective diarrhoea the problem is in the
transport pathways of water and electrolytes in the
gut wall and not in the motility hence antiperistaltic
agents have no role in such diarrhoeas.
Drugs such as opiates, diphenoxylate and lopera
mide which reduce bowel motility, although widely
used, should never be given to children. By slowing
peristalsis they make the situation worse—this has
been seen in a number of children and in volunteers
with shigellosis." These drugs also depress respiration
and are an important cause of accidental poisoning.16
Lomotil
Lomotil is one of the popular brands of diphenoxylate/atropine made by the U.S. multinational drug
company G.D. Searle. It is promoted to physicians all
over the world in terms such as "established success".
"good tolerance", "excellent value" and "ideal for
every situation". Lomotil may be of value in giving
symptomatic relief for non-specific "travellers diarr
hoea" in adults. But experts say Lomotil—and other
products like it have little or no place in the treatment
of young children. As a typical anti-motility drug, it
carries all the hazards described above including
masking the signs of dehydration and sometimes caus
ing fatal toxic reactions. Moreover Lomotil costs upto
25 times more than other widely used symptomatic
treatments of diarrhoea.17
The following tables show some of the brands of
diphenoxylate clioquinol, and chloramphenicol—strep
tomycin combinations available in India.
This is followed by an analysis of commercial pre
parations of ORT packets.
25
BRANDS CONTAINING DIPHENOXYLATE
Antidiarrhoeals
*t Lomotil
(Searle)
Diphenoxylate hcl
2.5 mg, atropine sulph.
0.025 mg
10-1.84
*t Lomotil
Liquid
(Searle)
Diphenoxylate hcl
2.5 mg, atropine sulph.
0.025 mg, alcohol 0.79
ml/5ml
20ml-2.22
60ml-6.59
*t Lomofen
(Searle)
Diphenoxylate hcl
2.5 mg, atropine sulph.
0.25 mg, furazolidone
50 mg
10-1.97
Symptomatic relief of
diarrhoea
Atropine intolerance and
Children above 2 yrs
0.25 mg of diphenoxylate jaundice, hypersensitivity to
diphenoxylate hcl, diarrhoea
hcl/kg body-wt daily in
associated with pseudo
divided doses
membraneous enterocolitis
(Same as above)
Bacterial diarrhoea
with gastro-enteritis
or food poisoning
(Same as above)
Hypersensitivity to active
ingredients entero-colitis.
Hopatic disease, ulcerative
colitis and patients
on narcotics, addicting drugs
or MAOIs alcoholic beverages,
G-6 PD def.
(Same as above)
HEALTH FOR THE MILLIONS OCT./DEC.
t Lomofen
Susp.
(Searle)
Diphenoxylate hcl
2.5 mg, atropine sulph.
0.025 mg, furazolidone
50mg
60ml-6.75
10-5.50
Diarrhoea of
bacterical origin
associated with
gastro-enteritis.
Children above 2 years
Corresponds to 0.25
mg, diphenoxylate
hcl/kg body wt. in
divided doses
(Same as above)
t Lomomycin Diphenoxylate hcl
(Searle)
2.5 mg, atropine sulph.
0.025 mg, neomycin
sulph. 250 mg
60ml-10
(Same as above)
(Same as abov9)
(Same as above)
t Lomomycin Diphenoxylate hcl
Liquid
2.5 mg, atropine sulph.
0.025 mg, neomycin
(Searle)
sulph. 250 mg
_____ _____ ________ ____ —
1983
* MIMS
t CIMS
health for the millions oct ./ dec . 1 9 8 3
Drugs Containing Hydroxyouinoline
BRAND
DRUG HOUSE
BRAND
DRUG HOUSE
Ambactin-4
Amoebindon
Aldiamycin
Aldiamycin Suspension
Alliquin
Amebys
Ambilan
Amoechin
Antidar
Bioxyl
Chlorambin
Colon
Davoquin
Dequinol
Dependal
Dysenchlor
Digichlor
Diodoquin
Di-Iodohydroxyquin
Di-lodohydroxyquinoline
Di-lodohydroxyquinoline
Di-lodohydroxyquinoline
Di- lodohydroxyqunoline
Dinochlor
Dinoquin
Di orcin
Dystrindon
Dysental
Dysentol
Dysentriad
Enteroton
B C PW
Indon
Alkem
Alkem
Standard Pharmaceuticals
Napha
Swastik Pharmaceuticals
Universal Drug House
Dextromed
Bio-Drug
Anglo-French
Emsons
Albert David
Dey's Medical Stores
S K aS
S G Chemicals
T H P
Searle
Semit
T H P
Fairdeal
Usan
Baropharn
Bengal Immunity
Bengal Immunity
Cos Pharma
Indon
Quality Pharmaceuticals
Bronkal Pvt Ltd
GDA Chemicals
I N D C
Entro lodochlor
Embaquin
Entrokin
Entroquinol
Entero-vioform
Intestopan-ln
Faircolin
Fairdiquin
Floraquin
Furoquinol
Histoquin
Idosulpain
Indoquin
Intestopan-Q
Intestopan Suspension
Labrody
Lumigyl Caplets
Mebinol Complex
M exaform
Neoquin
Moebagym
Phenipan
Quiniform
Quinogel Compound
Stadmed Entrozyme
Sulfaquinol
Sulphaquino-Bael
Sulphazyme
Uni-Dys
Yodchin Sulpha
Bombay Tablet
M a B
Bengal Chemicals
Indo-Pharma Lab
Ciba-Geigy
Sandoz
Fairdeal
Fairdeal
Searle
Chogule
Zandu
Indo Pharma
Indoco
Sandoz
Sandoz
Labros Chemicals
Ethico
MAC Labs
Ciba-Geigy
Sun ways
Ebers
Sandoz
Albert David
Acilla
Stamed
Comteck
Standard Pharmaceuticals
INDC
Unichem
Duphar, Navaratna
Drug Containing Combinations of Chloramphenicol and Streptomycin
BRAND
DRUG HOUSE
Basi
Basiplon
Basiplon Suspension
Chforostrep Kapseals
Chlorostrep Suspension
Enterostrep ,
Enterostrep 'C'
Enterostrep Suspension
Halcetins
Khandelwal
Khandelwal
Parke-Davis
Parke-Davis
Dey's
Dey's
Dey's
Hal
BRAND
DRUG HOUSE
Ifistrep
Ifistrep Suspension
Reofin
Retostrep with neomycin
Strepto-Paraxin
Strepto-Paraxin Pediatric
Streptophenicol
Streptophenicol Syrup
Unique
Unique
Rallis
Retort
Boehrnger-knoll
Boehringer-knool
Mercury
Mercury
The Dangers of Anti~Dia rrhoeals
Commercial Preparations
S. No.
Brand Name
2. 2. 1
Electral
(Fairdeal)
.
Ca fact.
KCI
0.545%
2.337%
MgSo4
Naacid Po4
0.736%
NaCitratel
Dextrose to
make 80gC
»
2. 2. 2.
Composition
Electral-Forte
(Fairdeal)
0.975%
1.839%
NaCI
4.914%
NaHCoa
8.07 %
NaCitrate
4.9 %
KCf
2.9 %
Kdihydrogen
Po4
1.36 %
Calact
1.232%
Mg So4
0.984%
Dextrase to
make 75 gm.
2. 2. 3
Emlyto
(mm Lab)
NaCI
NaHCo3
KCI
Glucose to
make
3.5g.
2.5g.
1.5g.
Price
Comments
7-NP
—Extra dextrade added
—Does not follow WHO
formula
—Ca++, Mg++ not necessary
4-18
—Costly.
— Does not follow WHO
formula.
—Unnecessary electrolytes
added.
5-34
3-98
—Extradextrase added.
-Costly.
— Follows WHO formula
—Extra glucose added
—Costly.
35g.
2. 2. 4
Emlyte-S.
(mmLab)
Same as Emlyte
4-59
Cost is increased without
any change in composition
or quantity.
2. 2. 5
Orhynrate
(Alkenm lab)
NaCI
NaHCo3
KCI
Calact
MgCI2
Glucose
3.5g
2.5g
1.5g
0.44g
0.6g
19g
R-NP
Very close to WHO formula
Cheaper
NaCI
NaHCo3
KCI
Glucose
7g
5g 2 Lit
3g water
40g
2. 2. 6
28
Prolyte
(Cipla)
2-25
Exactly follows WHO formula
3.00
Cheaper
HEALTH FOR THE MILLIONS OCT./dEC. 1983
The Dangers of Anti-Diarrhoeals
Brand Name
S. No.
2. 2. 7
2. 2. 8
2. 2. 9
Lactolyte
(Dolphine-Lab)
Egolyte
(Ego-Pharma)
Eiectropec
(Fritz-Pharma)
Each 10ml
2. 2. 10
Eiectropec
—F(Fritz-Pharma)
Price
Composition
Calcact.
KCI
MgSo4
NaCI
Na acid Po4
NaCitrate
Doxtrose to
make 50g.
2.18%
2.337%
0.736%
0.365%
0.975%
1.839%
NaCI
0.5g
NaHCo3
KCI
Dextrose
0.75g
0.5g
20g
Light Kaolin
1g
Pectin
KCI
CaCI2
Na Lact
NaCI
Dextrose
50mg
74mg
50mg
125mg
150mg
1g
3.38
5-50
4-90
2. 2. 12
Electrolyte
Powder
(Kasturba
Hospital B'aay)
NaCI
MaHCo3
KCI
Glucose
3.5g
2.5g
1.5g
20g
1-30
Home preparation
with Salt/Sugar
Sugar
Table salt
water ___
8 Tsf
1 Tsf
1 lit
0-50
either high (usually 50) or low.
Instead of standard sodium chloride and sodium bicarbonate
which are cheap, salts like sodium citrato and phosphate are
used, which are costly and have no extra-advantage over
standard salts.
These preparations contain many other electrolytes like cal
cium, magnesium etc. which are not so necessary in the treat
ment of dehydration. They unnecessarily increase the solute
load and price.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
No correlation with WHO
formula
Unnecessary electrolytes
are added
Pectin and Kaolin has no
role
5.25
5.50
Comments
(1) Majority of these preparations do not follow the WHO
formula in a stricter sense, i.e. their electolyte content are
Does not follow WHO
formula
Very much low electrolyte
content
Costly
Unnecessary a-biotic is
added
60ml bottle
same as Eiectropec
4-Furuzolidine 50mg
60ml bottle
Same as Eiectropec
4- Neomycin
(3)
Unnecessary electrolytes
are added
Extra-glucose is added
Costly.
Eiectropec
N
(Ftitz-Pharma)
(2)
____ ____
Costly
2. 2. 11
2. 2. 13
Comments
No correlation with WHO
formula
(4)
Few preparations havo caolin and Pectin added to them with
an antibiotic like Neomycin, without any extra-advantage to
the patient.
(5)
All these preparations (except two) have very high glucose
content. Glucose in excess off 20 gm/lit. has no extra advan
tage in enhancing electolyte absorption and on the contrary
may worsen the diarrhoea.
(6)
No mention or precautionary note is added regarding their
use in infants (all tne children below the age of 2 years).
(7)
All these preparations are used by doctors indiscriminately,
whether indicated or not.
(9) All these preparations are available 'over the counter'.
29
The Dangers of Anti-Diarrhoeafs
9.
Weyman H, Tetracycline and Teeth. Practioner 1965, 195,
661-665.
13.
Grossman, E.R; Walchick, A; Freedman, H: Tetracycline and
Permanent Teeth: The Relationships between doses and
Tooth Colours: Pediatrics 1971, 47, 567-570.
Dupout H.L. Sullwan P.P., Pickering L.K. et al. Symptomatic
treatment of diarrhoea with Bismiuth subsalicylate among
students attending a Mexican University. Gastroenterology
73: 715, 1977.
14.
3.
Goodman Gillman: Pg 1188, 6th Ed: Goeke T.M., Jackson
G.G, Grigsby M.E, Love Bd Jr. and Finland, M.
Dupout H L, Hormick R.E.—A Clinical Approach to Injec
tions. Diarrhoea Medicine: 32, 265, 1973.
15.
4.
Arch Interm. Med 1958, 101, 476-513.
Fingil E, Freston J W: Anti diarhoeals and caxatives—A
Changing Concept: Clin. Gastro Enterology —8:16, 1979.
5.
Cohlan SQ, Bevelander G, and Tiamsic T: Growth Institu
tion of Prematures receiving Tetracyclines—Clinical and Lab
Investigations Am. J. Dis. Child 1963, 105, 453-461.
16.
Prof. H.P. Lambert: Drugs and Treatment of Diarrhoeal
Diseases—Caxtious Prescription Diarrhoea dialogue: Feb 1982.
17.
6.
Goodman, Gilman 6th Ed.
7.
Shultz J G, Adamson J.S. Jr, Work, an W W, Morman T.D,
Fatal Liver Disease after intra-venous Administration of
Tetracycline in High Dosage. N. Eng J. Med. 1963: 269,
999-1004.
Upunda G., Yudkin J, Brown G: Therapeutic Guidelines (A
Manual to assist in the rational purchase and prescription of
drugs) (Nairobi—African Medical and Research Foundation,)
1980) p. 96.
10.
'Clioquinol: Time to Act', editorial in "The Lancet" 28-5-1977
p. 1139.
11.
Pharm. J. 30 July 1977 p. 597.
12.
Drug Controller of India in an interview with VHAI
nnel.
References:
1.
2.
8.
Chandrashekharan R, Kumar V, Murthy B, Walia BNS Car
bohydrate Intolerance with Acute Diarrhoea and its Compli
cations Ac. Pediatr. 14:449, 1977.
Pride G.L. Clearly R E and Hambuvger R. J. Disseminated
intravascular coagulation associated with tetracycline induced
hepato renal failure during pregnancy. Am J. Obst. Gynae.
1973, 115. 585-586.
perso
Pleased and Encouraged
Dear Editor,
We have just had the pleasure of a 6-day course in T.A. by Sr. Carol Huss and
Sr. Celine P. of Pune. Sr. Carol gave me a copy of your June 1983 issue of HEALTH
FOR THE MILLIONS.
As I am very much interested in promoting nonsexist language, I saw that in your
editorial * ‘To Live or not to Live’ ’ , nonsexist language prevails throughout. I
felt so pleased and encouraged I had to write you at once. For several years our
Bishop Morrow (founder of our congregation) has been trying to promote the use of
nonsexist terms. I have been assisting him. But it has been like voices crying
in the wilderness.
Here in our congregation we are trying to alter masculine expressions to neutral
ones , in our liturgical prayers and hymns .
Since more and more women are feeling ‘ ‘left out’ ’ by the constant use of ‘ ‘man’ ’ ,
‘ ‘ sons ’ ’ , ‘ ‘brothers ’ ’ * ‘ fellowship ’ ’ , etc. , I feel sure that in time, the more
caring persons among editors and journalists will adopt the policy of using
neutral terms.
Thank you, dear sir, for your apparent compassion and fairness towards women as
seen in your editorial.
Krishnagar, W. Bengal
October 13, 1983
3)
Yours etc.
Sr. Frances H. Espnr, S.M.I.
HEALTH FOR THE MILLIONS OCT./DEC. 1983
22 combination
drugs banned
‘
Express News Service
BOMBAY, Aug H• .The UniOn Government has is
sued a gazette notification prohi*
•’•nine the manufacture and sale
d W fixed-dose
combination
Ministry of He?hat
^The Union
.nd Family. Wellare , OT
drugs is HKely
•lie l,se c
human beings,
xj involve £
not 'have
or that ’
s clairi^
therapeutic
The dr
vitamin*’
as*”*
A>nonamid<
min C, hydv
drugs except
are used *r
diarrhoea
extxerna’
.«
terns'
'
stere
treat .-»iv
0
phenlcol for
vllnmlnsl
urgus- except corn
with
er isoniazide with pyrlbiratlc
hydrochlorlde (vitamin
B-6)nt oenciHio "skin.eye ointment,
tetracycline liquid o™l prC,paJ1p"
Mons, nialamide practolol and methapyrilene and its salts.
It may be recalled that some
Mme ago the Health Ministry had
banned
.18 categories of.- flxeddose combinations after consulting
the Drugs
Technical
Advisory
Bosard.
A ecurlty of tuhe two lists re
veals that, while preparing the
new list, the
Government has
deleted "fixed-dose combinations
of ayrvedic or unani drugs with
modern drugs”. and has
added
pencilim sUneye ointment, tetra"yUne liquid
ord preoarauons,
nilanlde
practolol
and meihapyrilene and its salts.
Opinion on the need to
ban
these drug* is sharply
divided.
Some medical practitioners
and
specialists feel
that considering
the conditions obtaining in differ
ent parts of the country, the Gov
ernment had acted •'hastily”-
MINISTRY OF HEALTH AND FAMILY WELFARE
NOTIFICATION
New Delhi, the 23rd July, 1983
G.S.R. 578 (E).—Whereas the Central Government
is satisfied that the use of the drugs specified in the
Table below is likely to involve risk to human beings
HEALTH FOR THE MILLIONS OCT./dEC. 1983
or the said drugs do not have the therapeutic value
claimed or purported to be claimed for them or con
tain ingredients and in such quantity for which there
is no therapeutic justification and it is necessary and
expedient in the public interest so to do :
Now, therefore, in exercise of powers conferred by
section 26 A of the Drugs and Cosmetics Act, 1940
(23 of 1940), the Central Government hereby prohibits
the manufacture and sale of the said drugs namely :
TABLE
Amidopyrine.
Fixed dose combinations of Vitamins with antiinflamatory agents and tranquillisers.
3. Fixed dose combinations of Atropine in Analgesics
and Antipyretics.
4. Fixed dose combinations of Strychnine and Caffeine
in tonics.
5. Fixed dose combinations of Yohimbine and Stry
chnine with Testosterone and Vitamins.
6. Fixed dose combinations of Iron with Strychnine,
Arsanicand Yohimbine.
7. Fixed dose combinations of Sodium Bromide
Chloral hydrate with other drugs.
8. Phenecatin.
9. Fixed dose combinations of anti-histaminics with
anti-diarrhoeals.
10. Fixed dose combinations of Penicillin with Sul
phonamides.
11. Fixed dose combinations of Vitamins with
Analgesics.
12. Fixed dose combinations of Tetracycline with
Vitamin C.
13. Fixed dose combinations of Hydroxyquinoline
group of Drugs except preparations which are
used for the treatment of diarrhoea and dysentery
and for external use only.
14. Fixed dose combinations of Steroids for internal
use except combination of Steroids with other
drugs for the treatment of Asthma.
15. Fixed dose combinations of Chloramphenicol for
internal use except combination of Chloramphanicol and Streptomycin.
16. Fixed dose combinations of Ergot.
17. Fixed dose combinations of Vitamins with antiT.B. drugs except combination of Isoniazide with
Pyridoxine Hydrochloride (Vitamin B 6).
1.
2.
18.
19.
20.
21.
22.
Pencillin skin/eye ointment.
Tetracycline liquid oral prepatations.
Nialamide.
Practolol.
Methapyrilene, its salts.
[No, X-11014/V83-DMS & PFA]
S. V. SUBRAMANIYAN, Jt. Secy.
31
Andhra Pradesh
NEWS
From the States
Kerala
NEW PLANS
Recent reorganisation has led the Kerala Voluntary
Health Association to plan a series of seminars, train
ing programmes and workshops on the National Health
Policy (November '83), workshop on community health
November '83), Seminars on Managing Personnel in
Health Related Institutions (December '83—Jan. '84).
KVHS will also compile a Directory of Voluntary
Health Care Institutions and their services and conduct
a survey on training personnel management systems
in voluntary hospitals.
SCHOOL HEALTH
APVHA conducted an intensive four-day workshop
on School-health from September 7 to 11. There were
22 participnats. The course was directed by Dr. Mira
Shiva, VHAI. Topics covered were : Health Situation
and health services in India and the role of school
health programme in Community Health Works. Health
Education—its objective, contents and methodology;
organising and planning a school health programme;
—(earning and teaching methodologies; importance
of child to child activities; dealing with Dental, ENT
and Pediatric Problems; health assessment tools for
teachers; planning action for respective schools;
'School Health' will be the theme of the next APVHA
annual convention. A School Health Newsletter will
also be brought out.
Delhi
CONGRATULATIONS
An'expert panel' will help small institutions in
planning the recruitment, training and upkeep of
human resources and materials.
Three VHAI staff L.K. Murthy, P.T. Thomas and
Dayaram on completion of ten fruitful years of work
with the organisation were given awards by way of
special increments for their devotion and service.
For further information write to : Jose Varghese,
Programme Officer, Rajagiri College of Social Sciences,
Rajagiri, P.O. Kalamassery-683104 (Kerala).
Wanted :
Hardworking and responsible personnel.
(1)
Female Doctor D.G.O or M.D. I M.S. or
M.B.B.S. and 2 years experience in Ob/Gynae.
(2)
Male Doctor M.B. B.S., D.C.H.
ONE MORE
(3)
Female I Male Ophtalmologist Dip/Degree
WBVHA in collaboration with Child in Need Insti
tute and the All India Institute of Hygiene and Public
Health held a one-day seminar on the National Health
Policy in Calcutta on September 16. Some of the
topics covered were • Health and Medical Education
changes and modifications necessary to be in keeping
with the NHP; the role of doctors, paramedics, auxi
liaries, community health volunteers; use of lowcost
drugs and. rational therapeutics; role of drugs and
drug industry; jnteripeshing of government and volun
tary agencies; and role of panchayat'in health care.
(4)
Sister Tutor.
(5)
Female Pharmacist D. Pharm or Bipharm.
West Bengal
‘ 32
Female I Male Laboratory Technician C.M.A.I.
Trained.
(Salary Scales under revision).
(6)
Please apply immediately to : The Medical Superintendent, St. Columba's Hospital, Hazaribagh P.O. &
District, Bihar-825301.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
AWAY TO MAKE MEASURING SPOONS
FOR PREPARING SPECIAL DRINK
Children can make measuring spoons from
many things. But it is important that they
measure roughly the right amounts of sugar
and salt.
Here is one way to make spoons, using
things that have been thrown away.
Make this part as wide as a pencil
HOW TO MAKE
SPECIAL DRINK
Put 1 heaping
bottle cap of
SUGAR
and 1 little
spoon of
SALT
2. Wrap this part tightly around a pencil.
3.
In the middle of a
bottle cap make
a small cut.
a medium-sized glassy
\of WATER and mix well’.
4. Join the pieces
and bend over the tabs.
Give the child
1 glass of SPECIAL DRINK
for each time he makes diarrhea.
Before giving this
SPECIAL DRINK,
taste it to be sure it
is no saltier than tears.
Another kind of measuring spoon can
be made by drilling holes in a small
piece of wood.
MORE APPROPRIATE
Drill the holes to be as
wide and deep.as shown in
the drawing at right. Or you
can carve the holes, taking
care to make them the right
size. A model plastic spoon
like the one shown above can
be used to check the sizes
of the holes you have made.
If you do not have a drill for making the.wooden
measuring spoon, you can try using a red-hot bolt
about this size.
Heat the bolt in a fire,
and use it to burn two
holes in a piece of wood.
Use the big end
for the sugar.
Use the small
end for
the salt.
Use a model plastic spoon (if you
have one) to check if each hole is the
right size. If the hole is too small, burn
it deeper. If it is too big, shave some
wood off the top.
Yet another kind of measuring spoon can be made out of bamboo. Find 2
pieces of bamboo with hollow centers about as big around as the scoops of the
Cut the bamboo so the dividers form cups that can hold just
a little more than the scoops of the plastic spoon. File or trim
them until they hold the right amounts of sugar and salt. Then
slip the two pieces together to form a double-headed measuring
spoon.
The important thing in making homemade spoons is to
encourage local people to use their imaginations to adapt
whatever materials they have on hand. But at the same time,
care must be taken to see that the spoons are reasonably
accurate.
appropriate as a model
Sugar
Salt
Make Your
Plastic measuring spoons for making
Special Drink are now being used in
several countries. They are distributed by
TALC (see below.). For those who can
read, a big advantage is that instructions
are printed right on the spoon.
Unfortunately, these spoons have
some of the same disadvantages as the
packets of rehydration salts. They are
produced using high technology (plastic),
so people must depend on an outside
supply. Also, they add a sense of
mystery to what is basically a simple
process. (A mother may feel unable to
make the Special Drink because she has
lost her 'magic' plastic spoon.) So TALC
now recommends that the plastic
spoons be used mainly as models for
health groups, school children, and
villagers who want to make their own
spoons using local resources. For that
purpose, TALC will send a free sample
spoon on request.
own
Measuring Spoon
[See Cutout overleaf]
Before you cut and paste :
• Trace out the drawing and keep it for future use.
• Use the tracing to teach others how to make the
spoon.
• Experiment with Plastic
Sheets, tin and
materials which may be more
other
appropriate and
lasting.
This cardboard spoon is
the equivalent of the
standard Talc Spoon. Since it may not last forever,
use this spoon to standardise measurements for
sugar and salt by comparing it with metal spoons
or containers which you regularly use at home.
TALC
30, Guilford Street
London WCIN-IEH
To Make the Spoon :
1.
Cut along the solid lines
2.
Fold along the dotted lines.
3.
The strip with panels marked a-b-c-d goes
right round the square cup formed by sides
1,2,3, 4.
4.
Use paste or a bit at cello-tape to fix panel
'd' to side 4.
5.
This is what the completed spoon looks like:
The dimensions of the sugar cup: 2cm x 2cm x 1 cm.
The dimensions of the salt cup:1 cm x 1 cm x 0.7 cm.
Diarrhoea and Malnutrition
MORE FOOD
MORE CHILD
We'are painfully aware of the malnutrition-diarrhoeamalnutrition cycle. But what exactly are the causes
leading to malnutrition in diarrhoea probably need a
brief review.1
Diarrhoea is more severe and longer in the mal
nourished. Diarrhoea aggravates malnutrition in four
ways:
1. Loss of appetite (Anorexia)—this being the
most important.
1.
2.
Withholding of food by family and by the
person treating the patient.
3.
Reduced intestinal absorption both during and
after diarrhoea (Nutrient malabsorption after
diarrhoea caused by common rota virus is
worse than after cholera as shown by the
Bangladesh study.)
4.
Metabolic breakdown of muscles and fat due
to fever or inadequate intake.
Reduced food intake is mainly due to child
ANOREXIA—loss of appetite. The causes for
due to child anorexia. This re-emphasised the need to
rehydrate and deal with electrolyte imbalance as early
as possible.
Martorell & Yarbrough found in a Guatemalan
village that there was an average reduction of calorie
& protein intake of 20%, equivalent to 175 kcal and
4.8 gm protein per day in children with diarrhoea.
The negative effect of diarrhoea on food intake was
significantly greater than from any other infection.
With more severe toxigenic diarrhoea in children in
Bangladesh, food intake reduction was found to be
30-50%.
Children in the developing world, especially those
amongst lower socio economic groups are prone
to repeated gut and other infections, added to
malnutrition. These infections and their causes which
result in anorexia and decreased food intake have
therefore to be dealt with very seriously.
2.
Another cause of decreased food intake is
maternal food witholding behaviour. This
could be as a response to
this are mainly
• dehydration
• electrolyte losses, especially potassium
• abdominal distention and discomfort
• acidosis (due to loss of bicarbonates in stools)
• fever
• vomiting.
This results in a drastic reduction of food intake,
even cessation of breastfeeding by young infants. A
comparative study by Hayle et al in Rural Bangladesh
between 1. Control Children, 2. Children with diarr
hoea and 3. Children with diarrhoea whose mothers
encouraged feeding, showed that in spite of intensive
encouragement, increased food intake was not possible
HEALTH FOR THE MILLIONS OCT./DEC. 1983
(1) The child's anorexia and refusal to take food
(2) his vomiting or
(3)
or as
due to culturally ingrained dietary
practices
(4) her logical conclusion to withold food when she
observes feeding leads to his passing of stools (due to
the gastrocolic reflex stimulated by food ingestion m
the stomach). Witholding of milk products and
breast milk (which is considered to be heavy and
therefore difficult for digestion by a diarrhoeating
baby) is a common practice in many areas. Withhold
ing certain foods for a child with diarrhoea is practiced
widely. Withholding of foods like Gram flour (Besan),
Spinach (Palak ka sag), Chillies, Mustard oil, papayas,
33
Diarrhoea end Malnutrition
spices by the breastfeeding mother when her child
has diarrhoea is also known. Traditionally, as well as
according to the indigenous system of medicine lactat
ing mother and breastfeeding child are seen as a unit,
where mother's dietary indiscretion and psychological
state is expected to have an effect on the breastfed
baby. This causal relationship though widespread is
not accepted by those practising Western medicine.
rota virus and shigella in Bangladesh. Nitrogen lossesmay be between 200-400 mg per kg per day. Thisdecreases with recovery. Milk diarrhoea increased fat
excretion from 6-14% to about 28% and in severe
diarrhoea upto over 40%. Carbohydrate absorption is
decreased in diarrhoea due to Rota virus (which cons
titutes 50% of all diarrhoea) and shigella, but not due
to E-coli and Cholera.
We need to be familiar with these practices. In ___ Chung has shown that absolute absorption of
depth analysis of these practices is required, specially nitrogen and fat improved on higher intake even"
of those found all over India. This is to differentiate though fecal loss increased.
those which have some basis from others.
The result of living in an unsanitary environment is
3. Poor Absorption of Nutrients
not merely symtomatic but a symptomatic infection..
Malabsorption of macro and micro nutrients during The latter leads to subclinical malabsorption synd
rome known as subclinical chronic environmental.
acute diarrhoea has been documented. These are—
enteropathy, which is observed in the tropics. Chronic
— sugars-glucose, lactose, xylose.
ingestion of bacteria originating from contaminated
environment results in structural and functional changes
— fats
in intestinal mucosa-wherever if has been studied. It
— nitrogen aminoacids and proteins.
appears with variable degrees of severity in almost
every person living in an unsanitary environment and
— water and fat soluble vitamins.
beginning at a very early age. Colonisation of the
— trace minerals e.g. magnesium, zinc.
intestine by aerobic (those requiring oxygen) and unaerobic
bacteria occurs in these situations. When this
The causes of malabsorption during diarrhoea are—
happens and when there is no adequate compensa
• bacterial overgrowth in the bowel leading to tion, losses of specific nutrients result.2
bacterial fermentation of sugars, bacterial com
petition for certain nutrients.
• disturbed bile metabolism and disturbed pan
creatic functions (needed for breakdown of
fats, sugars and proteins).
# decrease (disaccharidase enzyme)
in the
brush border of gut lining. (Needed for break
down of sugars, for their absorption).
• death and shedding of mucosal cells, their poor
regeneration and therefore decreased absorptive
surface.
• quick passage of bowel contents, therefore less
time for absorption.
# Generation of abnormal osmotic forces prevent
ing normal movement of substances and nutri
ents from lumen info circulation.
A study in Indian preschool boys showed de
crease in protein absorption by nearly 20%. Decrease
by over 30% was observed in diarrhoea caused by
34
Role of the physician
"... the physican, as typically trained in
modern, high-technology, hospital-based medicine, is
singularly unsuited to direct community-based pro
grammes of diarrhoea prevention and other elements of
primary health care among disadvantaged populations.
Furthermore, notions of appropriate diarrhoea manage
ment as transmitted in the leading medical text books,
are outmoded for both developing and developed
societies in light of recent research findings, and have
been shown to be detrimental to the rapid recovery
of the patient. Efforts to reorient the physician and
other health professionals through training courses,
seminars, and wider dissemination of current research
results should be considered an essential component of
fostering the preventive measures".
—Lincoln Chen
HEALTH FOR THE MILLIONS OCT./DEC. 1983
Diarrhoea and Malnutrition
The implication of the above is serious. Poor sani
tary environment and poverty nor merely cause poor
food intake but also ensure greater losses of nutrients.
The question here is not of the presence of rota virus'
E coli or Shigella, but of criminal deprivation of a
large chunk of humanity of their rights to adequate
food, safe drinking water and environmental sanita
tion. Providing these is what the Alma Ata Charter
basic health care, and diarrhoea control are all about.
4.
DEATH
Poor Metabolism
It is known that catabolism i.e. breakdown of fats
and proteins is increased during clinical disease and
is related to severity and duration of fever.3
Briscal estimated that each degree of fever implied
basal metabolism increase of 5-8.2% i.e. more
calories and energy are burnt up. Repeated infections
with fever decrease appetite and food intake and are
also associated with catabolism.
a
Average daily negative nitrogen balance of 0.9 gm
per day was noted with diarrhoea of infectious
origin. According to Pollack, approximate loss of
130 gm of body nitrogen, roughly equivalent to 4 kg
body mass would occur with the usual 20 day course
of Typhoid.4
Direct loss
Hawland and Whitehead estimated that monthly
diarrhoea prevalence was associated with—4.2 mm in
linear growth and—746 gms in weight gain as seen in
Zambian village children.5 This was assessed by
studying infectious disease prevalence by monthly
body length and weight gain in Zambian children.
"Seasonally standardised regressions of the diar
rhoea and growth data suggest that had gastro
enteritis been eliminated completely, Zambian children
would have achieved growth rates of 200-400 gms
per month, in 10 months of the year, a velocity similar
to that of well nourished reference populations in
industrialised countries."
The chain of causes leading
io death from diarrhea.
the net retention of the nutrients by the body was
greater. Children who were fed recovered sooner and
gained weight better than those who were not fed.
WHO Scientific working group concluded in 1978
that lactose deficiency which is responsible for lactose
intolerance.. is generally not of clinical significance,
and it is not a contra-indication for either continued
breast feeding or feeding of milk formulas in diet.
Where clinical symptoms associated with lactose in
tolerance are suspected, a temporary stoppage for
8-10 hrs of milk feeds and their resumption in diluted
form and in small quantities may be indicated. Other
wise milk diluted in equal volume of water is fine.
Fluids well tolerated by children are butter milk,
rice kanji and banana, dal soup and sago.
Children who are fed with proper and adequate food
throughout the acute phase of watery diarrhoea—
©
absorb substantial quantities of nutrients and
therefore avoid nutritional deficiency
©
show better weight gains
©
have shorter duration of diarrhoea and recover
quicker than unfed kids.
Feeding during Diarrhoea
Feeding during diarrhoea is highly recommended.
Studies in the 40's showed that though the frequency
and volume of stools were more when a child was fed.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
35
Diarrhoea and Malnutrition
Breast feeding during Diarrhoea
The relationship of bottle feeding to diarrhoea is
well known. Bottlefed babies had diarrhoea six times
more frequently than breastfed babies as shown by
results of a survey done by school children of Ajoya,
as part of Project Piaxtala's School Health Pro
gramme. This is surely, an expensive way of ensuring
diarrhoea.
Birth weight appears to be an important prognosti
cation for the severity of diarrhoeal morbidity ex
perienced in infancy. Watkinson has shown that
children with higher birth weights receive greater
quantities of breast milk and experience less diarrhoea
induced growth faltering during infancy than their
lower birthweight counterparts.6
Breastfeeding should continue even during diarr
hoea. Anorexia of diarrhoea does not affect breast
milk intake. Breast milk contributes by providing
fluids for rehydratation and meeting nutrient needs.
Other foods should be given after breast feeding not
before; bulky low calorie foods being avoided. Since
fats are absorbed during acute diarrhoea, oils may be
added to increase calorie densify. Some doctors do
not agree with this point of view.
Breastfeeding
reasons :
must be
continued for various
1. Breast milk supplies the baby fluid calories as
well as nutrients and electrolytes like potassium.
2. Discontinuation of breast feeding and fasting
may lead to decrease or cessation of breast milk and
this may make the baby more prone to malnutrition
and infections. So-called "resting the bowel" leads to
diminished capacity to absorb glucose, salt water and
amino acids.
arm, nor even spoonfulls of ORT can provide this, but
the mother who breastfeeds her baby can.
6. In a hospital study, if was observed that breasffed children had a total calorie intake 35% greater and
a profein intake 2i times greater than children who
were completely weaned. Breastmilk is a low cost,
highly nufritious unconfaminafed food source.
7. The reduction in calorie and protein comsumption during sickness is also minimised and fhere is no
negative metabolic balance and weight loss.
8. There is no evidence of milk intolerance in
breast fed infants. This may be because acquired
lactose deficiency does not commonly begin in the
first year or two of life.
A newborn baby can be immediately put to the
mother's breast. This not merely activates the letting
down reflex for increased milk flow, but ensures that
for the first three days the baby gets the priceless
("specially created for the baby") 'colostrum' which
contains antibodies able to deal with infection. Suck
ling at this time also helps in retraction of the uterus
and early cessation of bleeding after delivery.
In many hospitals and health centres the trend to
separate the baby into a nursery to feed artificial milk
and to introduce this baby killer to the mother con
tinues. This is not merely substandard practice of
medicine, it is a crime against the children.
For more details on the subject, refer to the
"Infant Nutrition Information Service"—a UNICEFVHAI protect at the VHAI Office, C-14, Community
Centre, SDA New Delhi-110016.
3. The child needs the milk to build up his im
munological defence and fight against infection.
4. A healthy child who is fasting loses on an
estimate 1-2% of body weight daily. In addition to
this, if the child has diarrhoea, the loss is much more.
5. A sick child needs the mother's protective arm
and closeness. Neither an I.V. needle stuck in a baby's
36
health for the millions oct./dec. 1983
Diarrhoea and Malnutrition-
Convalescent Feeding
Experience has shown that after diarrhoea, appetite
returns and is usually increased. During the early
period after the illness, the child should be fed his
normal diet, but in increased quantity, nearly 1 i times
his normal quota, and an extra meal daily till he regains
■or exceeds his pre-illness weight. This should be con
tinued for at least one week after the diarrhoea
stops.
The food deficit is roughly equal to the food which
-remained unconsumed during the illness and the
replacement should take place within a short period,
the duration of which should not be more than 2-4
times the duration of the illness. If the replacement is
done slowly, over the months, stunting will occur and
even after reaching normal weight ratios, catch up
growth" will not be possible.
Convincing and ensuring that the mother feeds her
•child during the diarrhoea is one of the most difficult
aspects of diarrhoea care. Its importance cannot be
emphasised more.
After a diarrhoeal episode children should get 30%
in calories and 100% in proteins, 4 gm/km/day to
optimize repletion in young children depleted by
infection.7
The consensus is that in low income countries of
Asia Latin America and Africa—where repeated diarr
hoeal episodes in childhood are a rule the recommend
ed dietary allowance for protein should be 25-30%
Steering Panel on Health
The Health Secretary will head a Steering Panel to
co-ordinate and guide the deliberations of eight work
ing groups constituted by the Health Ministry to iden
tify strategies and policies for the Seventh Plan period.
The first group will review the strategies and policies
adopted during the Sixth Plan with regard to popula
tion stabilisation and acceptance of small family norm.
The second group on health and services in rural and
urban areas will review achievement of physical and
qualitative targets during the sixth planand recom
mend improved methods and strategies for 1985-90.
The third group will suggest result-oriented and cost
effective methods for curtailment and eradication of
malaria, filaria, TB, Leprosy and diarrhoea. The fourth
HEALTH FOR THE. MILLIONS OCT./DEC. 1983
above the 1973 FAO/WHO recommendation. (Ad-hoc
expert committee on Energy and Protein Requirements,
Rome 5th—17th August, 1981). In the 1st two
weeks after diarrhoea, kids should get extra meals,
extra nutrition.
High energy rich foods should be taken as soon as
appetite returns or at least around the time mainten
ance therapy is started, since 60% of normal absorp
tion of nutrients takes place even during acute diarr
hoea. Foods enriched with fats, oils sugar, jaggery,
dais, dairy products, eggs and meat should be taken
if affordable.
Easily digested foods should be given preference.
It is good to avoid foods with high fibre content, eg.
coarse fruits vegetables, fruit peels whole grain cereals
etc. Foods rich in potassium are extremely valuable.
References
1.
Adapted from "Diarrhoea and Malnutrition"—Edited by Lincoln
Chen.
2. Linderbaugm J., Harmon JW, Gerson C.D., Clinical malabsorp
tion in Developing Countries, American Journal of Clinical
3.
4.
5.
6.
7.
Nutrition, 25 : 1056-1061, 1972.
Keusch G.T. The Consequence of Fever, American Journal of
Clinical Nutrition, 30: 1211-1214, 1977.
Pollack H. Sheldon D.R. The Factor of Disease in World Food
Problem. J. Amer. Med. Association 219: 598, 1970.
British Journal of Nutrition 37: 441-450, 1977.
Tran Roy Soc. Trop. Med. Hyg. 75: 432-435, 1951.
Whitehead R.G.—"Protein and Energy Requirements of Young
Children living in developing countries to allow for catch up
growth of the infectious" Amer J. Of Clin. Nutrition 30: 1545-
1547, 1977.
group will take up diseases like cancer, diabetes and
hypertension. It would also recommend modifications
in the existing systems of blood banking, laboratory,
radio logical and other investigative services. The fifth
group will make recommendations in the field of medi
cal and health research and development projection of
financial and physical requirements for medical educa
tion and para-medical training programmes during
1985-90 would be taken care of by the sixth group.
The seventh and eighth groups will deal with health
information education and communication and pro
grammes and services under the Indian systems of
medicines and homoeopathy.
The Planning Commission expects the reports of
the groups by March 31, 1984.
37
Alternative Treatments in Diarrhoea Care1
Go in search of your People
Love them
Learn from them
Plan with them
Serve them
Begin with what they have
Build on what they know.
— Old Chinese verse
from “Helping Health Workers Learn"
Homeopathy
Dosage
Three pills, four times a day. Take in potencies of
•6x or 12x unless otherwise indicated.
Symptom Picture A—Patient suffers sudden
-attacks of diarrhoea, especially after exposure to severe
cold. A fever accompanies the attack and the stomach is
burning hot, as if there were a weight in the abdomen.
Stools are slimy and splintered, like chopped spinach.
The face is red and one feels great thirst. Much rest
lessness and flatulence accompany the condition.
Take ACONITE .
Note : As a general rule, aconite works on any
illness only in its beginning stages. If the diarrhoea
is well developed, consult the other remedies.
Symptom Picture B—Diarrhoea is violent, yet
disappears suddenly. There is nausea and much
sweating before and after attacks. The stomach is
tender to the touch, and cannot stand to be jarred.
There is great redness in the face, and the diarrhoea
pains are pinching, squeezing, and violent.
Symptom Picture D—There is much urge to
defecate, but diarrhoea comes in small quantities
and is dark, burning, watery, and offensive. The rectum
burns, as do the intestines, and there are violent
pains in the abdomen, causing patient to roll about
and display great anguish. Condition is better with
application of hot compresses or hot drinks, and is
accompanied by excessive vomiting, pale face, cold
body, dry tongue, and great prostration. This remedy
is especially good for ptomaine poisoning.
Take ARSENICUM
Symptom Picture E—There is a general sensa
tion of body coldness. Stools are profuse and watery,
and constricting, and are accompanied by great weak
ness, cold sweats and sinking feeling, excessive
vomiting, and distended abdomen. Patient thirsts for
great quantities of water. Diarrhoea often accom
panies a cold or flu.
Take VERATRUM ALBUM
Symptom Picture C—Patient is covered with
cold sweat and may retch violently. The pains cause
patient to double up and moan in agony. The diarr
hoea is green and foul-smelling like rotten eggs. In
children there is great crossness and unreasonable
behaviour; among adults, patients are irritable but
admit it. Diarrhoea may also be white and s imy. A
good remedy for the diarrhoea of teething babies, and
for children in general.
Symptom Picture F—Stools are green, usually
produced at night, and accompanied by a gnawing
pain in stomach. The food rises into the mouth as if
one would vomit, but vomiting takes place only long
after patient has eaten. There is much nausea after
eating and drinking, and it is accompanied by much.
gas and discharges of green mucus in the stool. There
is much rumbling and action of the intestines before
evacuation, and patient complains of a bitter mouth
and tongue. Patient often feels he or she has eaten too
much, even after a light meal. This remedy is espe
cially good for diarrhoea due to indigestion.
Take CHAMOMlLLA
Take PULSATILLA
Take BELLADONNA
38
HEALTH FOR THE MILLIONS OCT./dEC. 1983
Alternative Treatments in Diarrhoea Caro
Symptom Picture G—Stools are slimy, watery,
frothy, and produced mostly at night. The abdomen
feels continually inflated with gas. The diarrhoea is
painless and is apt to drive one out of bed at night,
especially around 5 : 00 A.M. The feet feel hot at
night and one continually puts them out from covers.
Condition is worse after eating, sleeping, and taking
a bath. The bowels are constantly gurgling, and
there is an intense urge to evacuate immediately upon
arising. The patient loves fat and sweet foods. A
^ood remedy when many other remedies have failed.
Take SULFUR
Symptom Picture H—There is terrible straining
before, during and after defecation. The stool is
sometimes mixed with blood. The colon feels as if it
has been bruised and is extremely tender to external
pressure. Condition is sometimes accompanied by
fever and bilious sensation. Evacuations are slimy,
frothy, and come in great amount. Patient feels that
he or she is never quite finished after a bowel move
ment no matter how great the discharge. Profuse
sweating often accompanies attacks.
breath slowly release. Repeat this movement until a
rhythm is established, and continue for three or four
minutes. Then return palms to the navel area, this
time using the heels of the palms to make downward
strokes from above the navel to the rim'of the pelvis.
Make the strokes long, deep, and wavelike, pressing
in firmly but not hard enough to cause pain.' Finally
have patient turn over onto his or her stomach,
place the palms directly on the sacral area at the base
of the spine, one palm on top of the other. Lean on
palms and apply a steady weight without moving
hands for three minutes, again concentrating on send
ing warmth and healing energy info the patient.
Complete the session by applying general message to
the lower back, the midshoulder area around the
scapulae, and beneath the armpits,
Acupressure
The following acupressure points can be stimula
ted to bring relief from diarrhoea. Press each point
three times, ten to fifteen seconds each unless
otherwise indicated.
1.
Take MERCURIUS
Press point directly below and to the inside
corner (i.e. toward the thumb side of the fin
ger nail on the middle finger.
MASSAGE
Have the patient lie on his or her back and expose
the stomach. Patient should take ten deep breaths
and concentrate on relaxing the stomach and back
muscles for several minutes before massage beings.
When ready, masseur rubs his or her hands together
for half a minute until they are warm, then places the
palms directly over the navel and keeps them there
half a minute, concentrating on sending warmth and
energy to the patient's inner organs. Then the palms
are placed one on fop of the other, held stationary
on the navel. Push down and rotate in a clockwise
direction with deep, concentrated pressure. If the
stomach feels hard and resisting, this means there is
a good deal of gas—as a supplement to massage,
charcoal can be given, or buttermilk, yogurt, (glutamic
acid-hydrochloride pills) B vitamins, or a spoonful of
apple cider vinegar in water.
After moving the palms in a circular pattern, place
the fingers of both hands just below the solar plexus
and ask patient to breathe in and breathe out deeply.
With each in breath gently push in, and with each out
HEALTH FOR THE MILLIONS OCT./DEC. 1983
39
Alternative Treatments in Diarrhoea Care
2.
3.
40
Draw an imaginary line across the head from
the top of one ear to the top of the other.
Draw a second imaginary line from the tip of
the nose to the hollow at the base of the
skull. At the point where these two lines
intersect is the point in question. Stimulate it
deeply with the thumb for thirty seconds.
4.
Press point in tha hollow of the inner elbow7
one inch to the outside of the center of thishollow.
5.
Measure the width of one hand down from*
the bottom of the kneecap along the shin
bone (tibia). From this point on the shin,
measure the width of two thumbs toward the
outside of leg (i.e., in direction of little toe),
Point is situated bet
ween the shinbone and
jlarge adjacent muscle,
and^ will be sensitive
when.pressed.
6.
Press the point on the
web of skin where
the big toe and the
second toe meet.
Press point on abdomen one and a half inches
directly below the navel. Rub this point with
deep pressure for thirty seconds.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
Alternative Treatments in Diarrhoea Care
Natural Remedies
1. Many natural doctors treat diarrhoea by plac
ing ice packs on the lower and middle parts of the
spine. The ice is kept there for ten minutes, then
removed and replaced again ten minutes later. Cold
applications on the back stimulate the nerve force
responsible for excretory functions.
2. Place two teaspoonsful of apple cider vineger
in a glass of water and drink before every meal.
This is a useful way of acidifying the stomach and
intestinal tract, and thus killing harmful bacteria.
3. For diarrhoea in infants, carrot soup, ground
bananas, at taspoonful of Chinese tea given at inter
vals of an hour or powdered carob dissolved in warm
water, are all helpful. For older children, lime juice
(Shikanji) hot lemonade (mullein leaves boiled in
milk,) or vinegar with a teaspoonful of salt added to
it can be taken.
Herbs
In general, there are a multitude of herbs that will
help stem the diarrhoea flow. Among the best, either
in tea form (steep an ounce to a pint of water) or in
capsules, are ;
basil—take it with a good fresh salad
garlic—on just about anything
peppermint—an old favorite, as a rule good for all
kinds of stomach ailments
Turmeric—take a capsuleful after meals
References
1. The complete Book of Natural Medicines by David Caroll.
National Children Fund (NCF)
Smokers vs Non-Smokers
NATIONAL CHILDREN FUND was constituted by
the Government of India, under the charitable Endow
ments Act 1890, during the International Year of the
Child, 1979.
Non-smokers have pushed a proposal to ban smok
ing in some General Assembly conference rooms, but
it ran into resistance from smokers and was dropped.
Dr. Halfdan Mahler, who is the Director Gene
ral of the World Health Organisation in Geneva,
had written to UN Secretary-General Javier Perez De
Cuellar suggesting that smoking be forbidden at all
UN meetings on grounds that tobacco had caused
"wide-spread illness."
The primary objectives of the fund are : To provide
financial assistance to voluntary organisations through
out the country to implement innovative programmes
for the development welfare of the children including
rehabilitation of destitute children particularly pre
school age and belonging to scheduled castes and
tribes.
The fund will provide assistance upto 90% of the
estimated cost of the project, subject to a limit of
Rs. One lakh for each project. The organisations raises
at least 10% from its own resources.
Projects for which financial assistance is not pro
vided by either the Ministry of Social Welfare, Central
Social Welfare Board/State Governments could also
be considered for assistance from National Children
Fund.
The proforma of the application form is available
I from :
Secretary Treasurer, National Children Fund,
National Institute of Public Cooperation and Child
Development (NIPCCD), Siri Institutional Area,
Hauz Khas, New Delhi-110016.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
Conference
The XII National Conference on Communicable
Diseases to be held in Christian Medical College,
Ludhiana from February 1 6 to 18, 1984 will discuss:
(a) Innovative approaches to control common Com
municable Diseases through Primary Health Care (b)
Newer Perspectives in leprosy and tuberculosis con
trol (c) Hospital acquired infections. For further infor
mation write to : Dr. M.L. Chugh, Department of Social
and Preventive Medicine, Christian Medical College,
Ludhiana-141 008.
CHVs on the Increase
By the end of 1984, 340,000 community health
volunteers will be trained to serve nearly 6,00,000
villages on the basis of one volunteer for a thou
sand population.
41
Traditional Home Remedies
Healing is a matter of time but sometimes also a matter of
opportunity. Hence medical practice must not depend primarily
on plausible theories but instead on experience combined
with reason.
—Hippocrates
Amongst the social functions of the traditional
household was simple home health care—diarrhoea of
infants and children was managed through dietary
control and special dietary regimes. If was a holistic
integrated approach to dehydration and associated
malnutrition, right in the home, where diarrhoea
begins and where if is firsf defected.
The biological diversity with which our country
was endowed allowed the emergence of diverse re
medies which experience found to be effective.
Unfortunately certain events and processes led to
the collapse of this comprehensive diarrhoea care
system in the home :
ful selection of the easily digestible high calorie liquid,
semi-liquid diets constituting of coconut water, rice
congee, sago, arrowroot conjee, bael sherbet etc.)
The present day ignorance, in view of the historical
process is still forgivable but the stuffing of diarrhoeating children with drugs and mixtures known to
be useless and hazardous in the name of scientific
medicine is definitely not.
Two types of ignorance have to be dealt with :
1. The ignorance that allowed reliable traditional
remedies to become distorted and unreliable.
2. The ignorance that allowed some of the dange
rous
modern cures to spread unchallenged.
1. Collapse of traditional information systems and
difficulties in availability of the resources especially by
There still exist some of these time tested home
the majority, (due to clearing of neighbouring forests,
remedies for diarrhoea control which are still low cost
increase in prices of ingredients etc.)
feasible options, if only they would once again be
2. With the decreased access to knowledge and come part of peoples knowledge.
resources, unreliable and distorted beliefsand practices
Considering the state of our health care services
crept in.
today, the magnitude of health care problems, the vast
3. Wifh fhe emerging market economy newer numbers of those who cannot afford them and there
problems of adulteration, faking, misinformation, hard fore have no access to health care, the self reliant
sell through use of advertisements led fo further dis options are the only real ones.
tortions of long known workable
decreased reliance on them.
remedies
and
It was not too long ago that the mothers of child
ren with diarrhoea used to be told very authoritatively
4. The domination and official recognition of by many of the medical profession to withhold fluids,
'western', 'modern' and so called 'scientific medicine, that rice congee caused diarrhoea, and make the sym
further marginalised and delegitimised home remedies. ptoms of diarrhoea worse—documentation of this is
available in some medical text books too. The fact
5. One powerful tool used by those who found the that rice congee was traditionally given for diarrhoea
commercial aspects of modern medicine profitable was treatment in so many parts of India (specially in South
to focus on the negative aspects of the distorted India), China and South East Asian countries, was
practices while ignoring the reliable and workable either not known, nor its significance realised. We can
ones (eg. it was the prohibition of foods and fluids advocate today, that which we were rejecting earlier.
in diarrhoea that was focussed upon, but not the care A cursory glance at the available material on simple
42
health for the millions oct./dec. 1983
Traditional Home Remedies
and widely practised home remedies, and discussions
with older folks, indicate that besides rice congee
many other therapies have been widely used.
Many of these home remedies are included in Ayur
vedic and Unani systems of medicine and in Nature
Cure. Some have also been documented in books like
the Indian Bazar Medicine Book. This book was written
by a British Doctor, an ex-principal of Agra Medical
College, with the aim of familiarising health personnel
with low cost effective alternatives. Most knowledge
of home remedies is handed down orally.
We need to appreciate the existence of the wide
range of indigenous, locally available products used for
oral rehydration and diarrhoea management. Especially
since most often the focus is on the ignorance, super
stition and the negative practices. Documentation,
serious study and comparative analysis of the effi
ciency, safety, cost, acceptability and availability of
these methods needs to be done.
— Boiled sherbet (wood apple)
— Pulp of 4 bael fruits (Aegle marmabis), boil in
1 pint of water, cool, add sugar or gur—take
2 oz. every 3 hrs. If bael fruit is unripe, roast
and mix pulp with water, sweetened with gur
for 1 glass, add 1 tsp sugar or gur.
— Dry bael giri 5 grains.
— Sugar or bura (unrefined sugar) 10 grains.
Grind fine, fake 6-7 grains daily every morning
with curd.
6-8 oz of green coconut water —rich in pottassium, uncontaminated, natural product, low cost
and easily available in coastal areas, used very
effectively for cholera by School of Tropical
Medicine, Calcutta.
— Sago and Arrowroot have been widely given for
diarrhoea.
— Dried fenugreek seeds (methi) mixed with ani
seed (saunf) and salt given in 2 to 1 drach
doses.
Some of the practices of managing diarrhoea are
being recorded with a hope that not merely the elec
trolyte' and 'energy' value will be assessed, but also
their other 'amoebicidal', 'bacteriocidal', 'anti helmin
thic' properties where gut infections and infestations
are concerned and also the healing and impact of these
therapies on the diseased gut mucosa.
— 1 part banana pulp, 3 parts milk, give 3-4
times.
A sincere effort towards low cost and rational
diarrhoea care is very much needed, and fortunately it
is very possible, especially since the solution is really in
the hands of the people.
— Juice of Plantain san Taube variety. Cut a
50 cm long stalk of plantain plant daily and
extract juice, filter and keep in bottles.
Simple fluids^
— Well-boiled, unripe fruit macerated in curd,
sugar, jaggery and a little salt.
— Weak tea with 2-3 teaspoons honey and a little
lemon in 1 cup.
— Buttermilk with or without lemon (salt and
sugar could be added).
Banana pulp (1 oz), Tamarind 2 oz,add salt 90
grains without seeds.
From flour of dried unripe plantain fruit make
chappathies, (4 oz for 1 chappathy) with curds
and butter.
— Roasted garlic (2-3) in buttermilk (1 cup/
glass). 2-1 tsp Methi (fenugreek) in 2-1 cup
curd.
— Jaiphala (nutmeg) (easily available in South)—
grind and make a pill with juice from betel
leaves (Pann Ka Patta). 5 grains given with
buttermilk three times a day.
— Small bits of yellowish inner-skin of tender
pomegranate (size of 5 paisa or 10 paisa coin)
fresh or dried with buttermilk.
— Decoction of guava leaves.
— Cummin seed boiled in water and cooled (jeera
water).
— Aniseed boiled in water (saunf water).
HEALTH FOR THE MILLIONS OCT./DEC. 1983
— Decoction of tender mango leaves with goat's
milk for childhood diarrhoea.
ISAPHGOL is recommended for chronic diarrhoea
and dysentery both bacillary and amoebic.
43
Traditional Home Remedies
— 2-4 heaped tea spoons of the clean seeds are in
fused with sugar in a cupful of water. When the mix
ture has become semi-solid fake in a single dose.
for acute dysentery.
— 1-2 tablespoonfuls of seeds, 2 pints water. Boil
volume to half. Take in several doses.
or 180 grains each of the seeds with sugar given
2-4 times/ day.
For more information read :
Everybody's Guide to Ayurvedic Medicine by
J.F. Dastur FNI, author of Reportory of Thera
peutic Prescriptions Medicinal Plants of India
and Pakistan, based on the indigenous medi
cal system.
Rice water congee2
Rice water congee has been used very sensibly in
many parts of the world. Forages, illiterate mothers
in many areas have been giving rice water to their
children, for diarrhoea, and even otherwise. According
to David Werner, women in Mexico have been using
it in this way even though rice is not the staple diet
of Mexicans, nor one of the cereals commonly used.
Rice is widely consumed, 60% of the world's
population eats it regularly. For these people, especially
the large sections not very comfortable with measure
ments, rice water could become the ideal ORS. Since
rice is boiled anyway, no additional fuel costs are
required. Again, there is no fear of contamination.
For best results the congee can be prepared as
follows :
Its effectiveness could be due to the starch-sugar
in the rice water which draws out less fluid into the
gut lumen as compared to glucose. (In one litre of
water, 80% of rice powder is converted to glucose).
The other reason could be that the starch in rice water
is more easily digested by babies than simple sugars.
Even one month old infants can digest and absorb a
large amount of starch. Salt takes care of the sodium
losses.
Studies done by Dr. Majid Molla at the Interna
tional Centre for Diarrhoeal Diseases Research, Bangla
desh (ICDDR) have also indicated the therapeutic
value of rice water for effective rehydration of diarrhoeal
cases. He has suggested the replacement of glucose
by 20 gms rice powder in the WHO formula. Higher
concentration of carbohydrate in the form of rice water
(as compared to glucose) can be used as this provides
extra energy as well as glucose in transportation and
absorption of the electrolytes without the danger of
osmotic diarrhoea. Carbohydrate absorption from a
rice meal is least affected during diarrhoeas caused by
cholera, ETEC and invasive organisms, rota virus or
shigella.
Possible disadvantages :
1.
Due to the hot tropical weather and lack of cold
storage facilities the rice congee may start getting
rancid.
2.
Rice powder makes the best ORS but this may not
be available, though plain rice water can be used
as well.
3.
In the enthusiasm to give the solution, its solid
content may be emphasised and its fluid content
overlooked—a thick gruel with less fluid may be
given.
• boil water with 20 gms of rice powder (even if
more is added there is no problem)
• add three pinches of salt
• squeeze 1 lemon, keep ready (if available)
• add lemon when solution has cooled.
Probably, the best thing that has happened with
respect to ORT is the acceptance of the findings of
Prof. Wong Hock Boon, a paediatrician from Singapore
who has been advocating the use of rice water for
rehydration therapy. Studies done by Prof. Boon and
Dr. Dilip Mahalanabis and others at the Kothari Centre
of Gastroenterology, Calcutta, have indicated that rice
based ORT solutions may be superior to the standard
WHO formula packet solutions.
44
References
1. 'Food Remedies' by Dr. S.J. Singh, MD, London.
2.
Dr. Majid Molla of ICDDR, Bangladesh, in the report of his
Study Published in ‘'Glimpse'. (Vol. 3, No. 11, Nov. 1981.)
in the article "Rice Powder as an Alternative to Sucrose in ORT."
Diarrhoeal Deaths—Approximately 5 million
children all over the world—40% mortality rate in
children upto 5 years of age in developing countries—
In India 15 lakhs every year.
—Unicef News issue 11-4- '82
HEALTH FOR THE MILLIONS OCT. I DEC. 1983
Programmes in Diarrhoeal
Disease Control—Problems & Prospects
To prevent death from diarrhoea will take far more than
latrines, pure water and nutrition centres. You may find that
wealth, land and power are more important in the long run.
—David Werner
WHO and the Control of Diarrhoeal
Diseases Programme (CDDP)
In 1978 the CDDP was initiated by the World
Health Organisation. This was in the wake of new
insights into the causation and management of
diarrhoea :
1.
2.
While 10 years ago only 30% causative organisms
were known, the etiology of nearly 80% cases can
now be determined.
Four Main Strategies in CDDP
1.
Case management—treatment with ORS
2.
MCH practices—continuation of feeding, specially
breast feeding
3.
Improvement of the environment—provision of safe
water
4.
Identification of morbidity and control of diseases.
Irrespective of the causative organisms, the fact
that effective management of diarrhoea through
rehydration with sugar and salt mixture was pos
sible was a rediscovery that became a milestone
in the progress of Diarrhoeal Diseases Control.
Surveillance
2.
To decrease the morbidity due to diarrhoea i.e.
number of diarrhoea episodes. WHO hopes that
in dealing with the latter, associated problems like
malnutrition will also be solved.
3.
To promote self reliance in the countries through
the processes and activities in controlling diarrhoeal
disease.
UNICEF would continue its support through the
development of ORT technology, in production of
salts, provision of these salts where necessary, whilst
looking for ways of simplifying technology to make
ORS from cheaper sources easily available.
Surveillance of diarrhoeal deseases is being under
taken and attempts continue for collaboration between
countries where diarrhoeal diseases are a problem and
3. The emphasis on health problems of the developing where the need to promote ORT programmes is recog
world and acceptance of the principle of primary nised and where planning, training and evaluation are
required.
health care as a priority was another reason WHO
was encouraged to be involved in the global
All 11 countries in the region are implementing
programme.
the programme. The ICDDR, Bangladesh, the
Objectives of the Programme
National Institute of Cholera and Enteric Diseases at
1. To decrease the mortality caused by diarrhoea in Calcutta, and another training institute in Bankok will
function as the main training and research centres.
children, using ORS.
WHO's support in Medical and Operational Re
search is concentrated on 3 aspects.
The programme was divided into two sections :
• Services—rendered
diaseases
for
controlling
diarrhoeal
• Research—having two components—Biomedical
research and Operational Services Research.
health for the millions oct./dec. 1983
(i) Research to improve technology of ORS (ii)
ways of providing ORS to the community most effec
tively. ie. through health services and generation of
health awareness about the diarrhoea problem and
(iii) use of ORT.
45
Programmes in Diarrhoeal Disease Control
Research Priorities
• Mode of transmission—bacteria, virus, etc.
• What makes the organism virulent
The long term objective was to decrease morbidity
due to diarrhoeal diseases through improvement in
environmental health by providing potable water
and sanitation facilities.
• Relationship of nutrition to diarrhoea is another
priority area
• Dry treatment in diarrhoea—WHO does not sup
port the use of drugs in diarrhoea, but it does
support research in the area.
Targets : Percentage reduction in mortality :
The National Diarrhoeal Diseases
Control Programme
It is expected that ORT can decrease diarrhoea morta
lity to less than 1% in communities as well as
hospitals.
On September 23rd 1982 a meeting was held in
Delhi to discuss action plans of the National Diarrhoeal
Diseases Control Programme (N.D.D.C.P.) organised
by the Ministry of Health. The participants were
mainly government officials in health services (with
no one from the voluntary health sector).
Budget Provisions
The information being shared is therefore only
second hand and based on the report of the proceed
ings. The idea of sharing this with our readers from
the voluntary health institutions is to:
focus their attention on this national health priority
and familiarise them with the government's
attempts
1
2 to encourage them to share their views, comments
and experiences in diarrhoeal disease control work
for the benefit of others in the field. Since many
of you have very valuable experience in this area
of work and since the Diarrhoeal Diseases Control
Programme is a national programme, by its nature
it should mean collaboration and cooperation of the
voluntary health sector in implementation as well as
decision making.
The Programme
Only during the 6th Five Year Plan was it
internalised that cholera constituted only 5-10% of
the morbidity* and mortality* due to diarrhoeal
disaeases. The need to seriously consider the other
diarrhoeal diseases was felt. NCCP (National Cholera
Control Programme) was renamed NDDCP (National
Diarrhoeal Diseases Control Programme).
* morbidity :—infection rate of the disease.
* mortality
death rate due to the disease.
The short term objective was to decrease morbi
dity and mortality due to diarrhoea.
46
1985
1990
2000
35%
75%
95%
A provision of about Rs. 16 lakhs has been made
for supply of health education material to the health
guides at Primary Health Centres :
The break-up is
Year
1980-81
Rs. (lakhs)
0.10
81-82
3.30
82-83
3.00
83-84
5.30
84-85
4.30
The production of material in different languages
is being done by the Department of Audio Visual Pub
licity (DAVP). Upto Rs. 1000 will be utilised at the
local district level for organising training programmes.
The disbursement of these funds will probably be at
the DGHS level.
Man power Development
Training would be organised for State and district
level doctors. 15 National Seminars were planned in
82-83 and 408 such training courses for PHC doctors
would be organised.
The input for ANM's and multi purpose workers in
diarrhoea management, would be integrated in their
routine courses. The National Institute of Cholera and
Enteric Diseases Calcutta would be responsible for
State level training.
The Rural Health Division has prepared Work Man
uals—for Rural Health Workers ["Work Manual for
Trainers and Health Workers"—available with WHO]
Operational Targets
The aim is that the control of diarrhoeal diseases
programme as an integrated part of primary health care
should cover all the PHC subcentres.
1981—5532
1985—6000
PHC
„
51184 subcentres
90,000
health for the millions oct./dec. 1983
Programmes in Diarrhoeal Disease Control
The villages will be covered by health guides, 1 for
•every 1000 population. The number of health guides
from 1.40 lakhs is to go up to 3.60 lakhs.
Requirement of ORS
Our under-five population is 93 million. The
average number of episodes per child is 2 per year.
10% of these episodes end in dehydration. A
rough estimate of ORS packs required would be
approximately 18 million.
Distribution
The primary Health Centres will get ORS packets
along with other drugs.
Sub centres
packets/year.
run by AN Ms will get 100 ORS
Health guides will get 20 packets/year.
About 100 packets of ORS will be supplied to
maternity centres, mostly urban. Ministry of Health
and Family Welfare has supplied 75 lakhs ORS Packets
to different States and Union Teritories. It would be
3.
Needless over-consumption of ORS packets for
mild diarrhoeas for which locally available home
made ORS would have been much better.
How this information will be obtained does not
seem clear, nor does there seem to be any attempt in
the proforma to seek information on the number of
diarrhoea cases not treated, treated by home based
ORT, and by ORS packets.
Adhoc study
The National Institute of Communicable Diseases
Delhi, All India Institute of Hygiene and Primary
Health, Calcutta, and the National Institute of Health
and Family Welfare, New Delhi will undertake some
adhoc surveys to measure morbidity and mortality due
to diarrhoeal diseases.
Production Capacity
Apparently IDPL at present produces 5 million
packets and MSD Madras 0 25 million. The Madras
plant has a capacity of producing 1000 ORS packets
per day. Private and commercial production output of
ORS packets is not known. The emphasis in the
NDDCP seems to be the production and distribution of
ORS packs through the health service system.
Operational Research will be aimed at determin
ing the deficiencies in the implementation of the
NDDCP with
special reference to distribution
and utilisation of ORS in terms of reduction of morta
lity, to find access/coverage of population, and to assess
implementation with regard to achievement of targets.
the responsibility of the State goverments to include
this item in the supply of medicine to PHC and sub
centres.
The BRAC Experience
The Bangladesh Rural Advancement Committee
(BRAC) designed a programme to train village
women in rural Bangladesh to use ORT with home
Surveillance
ingredients. Field workers were paid according to an
At State Head Quarters an officer will be in charge incentive salary system based on achievement of edu
of surveillance. He/she will apparently collect data on cational objectives. 8357 village women were taught
morbidity and mortality using a proforma for which one a short message about ORT and a method to make
PHC will be selected as sentinel area. The proforma oral solution using a local fluid container with finger
unfortunately
gives only the number of cases and scoop measurements of salt and unrefined sugar.
and deaths due to diarrhoea and numbers of ORS A random sample of 1079 of these women two
weeks after instruction showed that all those sampled
packets utilised. High utilisation could mean
knew how to make the solution correctly and 98%
1. Large number of diarrhoea cases in the area.
remembered 7 or more of the 10 points of the
2. Average number of diarrhoea cases but their effi health message. The women also made the oral
solution. Analysis of 996 of the solutions showed
cient identification and their acceptance of ORS.
HEALTH FOR THE MILLIONS OCT./DEC. 1983
47
Programmes in Diarrhoeal Disease Control
that only four had sodium concentrations greater than
120 mmol/lltre and all but 28(3%) had sodium concen
trations between 20 and 100 mmol/lif. The programme showed that safe and effective home solufions for ORT can be prepared, if training and
education are adequate.
The core of the programme was a simple, concise
but comprehensive health message entitled Ten
Points to Remember, which contained in substance
the following teaching points :
1. What is diarrhoea
2. Causes
3. Treatment, viz. ORT
4. What is ORT
5. How it is made
6. When to begin giving
7. How much of if to give
8. Dangers of
(i) too much salt.
(ii) too small feedings.
9.
When to consult a doctor :
(i) Diarrhoea lasts more than 2 days.
(ii) Patient cannot take fluids by mouth.
(iii) Severe diarrhoea and losses cannot be replaced
by mouth.
10.
Nutritional advice :
(i) During diarrhoea.
(ii) After diarrhoea.
Oral replacement workers (ORW's) used these ten
points to train village women to treat diarrhoea with
ORT.
The programme staff was composed of a project
manager, two monitors and two teams. Each team
consisted of team coordinator, ten ORW's and a ser
vice staff. The monitors maintained the quality of the
programme by verifying the ORW's reports, meeting
the women taught, examining the knowledge retained
by them, analysing samples of ORS etc.
An-important aspect of the programme was the ORW
incentive salary system. Each woman who was inter
viewed by a monitor was graded according to her
48
answers about the Ten Points to Remember and her
skill in preparing the mixture :
Grade A : Remembers all 10 points+makes mixture
correctly
Grade B : Remembers
correctly
7-9 poinfs-f-makes
mixture
Grade C : Remembers
correctly
1-7 points + makes
mixture
Grade D : Does not make the mixture correctly.
The ORW's were paid according to the number of
households visited that month in each grade, as
follows :
For each grade A household : 4 Taka
-
..
B
: 2 Taka
„ „
..
C
: 1 Taka
•, ,•
„
D
//
„
: no payment
The average ORW monthly salary was 600 taka/
(Rs 400/-)
The cost of the programme was approximately 6 taka/
(Rs 4/-) household visited
While demonstrating that village women can
learn oral therapy, including how to make oral solu
tion correctly, the BRAC experience also provides an
example of a workable system to supervise and ad
minister a rural health programme in a developing
country, based on achievement of educational
objectives.
Comments
The fact that the campaign against diarrhoeal
diseases should be taken as a national priority and is
sought to be dealt with through a well coordinated
effort under the National Diarrhoeal Diseases Control
Programme is indeed creditible.
Since it is a national programme, it would be
imperative for the voluntary sector to make a signi
ficant contribution in planning, implementation as
well as evaluation.
We would like to see the emphasis in ORT being
placed on easily available home based fluids, for early
and routine management of the mildest of diarrhoeas,
and limiting the use of ORS packets (with complete
HEALTH FOR THE MILLIONS OCT./DEC. 1983
Programmes in Diarrhoeal Diseases Control
formula) for moderate or serious cases, or in situations
where if is a problem to prepare salt and sugar solution.
This is because we strongly feel that ORS packets
will put the curative aspect of an otherwise easily
manageable problem into the hands of the health
personnel, with all its associated mystification, in
creased costs, unavailability of adequate number of
packets, long delays in starting treatment and an in
hibition towards local initiatives. As compared to no
treatment or treatment with intravenous fluids ORS
packets are a great advance. But not putting an equal
or greater emphasis on home based ORS—in view of
the present situation of our health services would be
an inappropriate and misguided strategy.
We would like to see the Department of Health
handling water and sanitation instead of department
of works and housing.
We would like to see studies done in traditionally
available ORS and the modifications that could easily
make these ORS more acceptable as well as rationally
sound.
The existing practices related to management of
diarrhoea and the belief-systems of the people and
medical personnel need to be studied. We hope that
these areas will be appropriately dealt with.
The need to ensure supply of potable water is
CRITICAL. Much more than ORS packets. Equally
important would be the health education related to
wafer related diseases, their prevention and low
cost and rational management.
A recent study in Gautemala has shown that inter
mittent water supply or water available at long dis
tances from human habitats do not have a signi
ficant impact on diarrhoeal problems. The results of this
study should not be misconstrued to de-link water and
diarrhoeal problems. If anything it underlines not only
the need for a potable water supply buf also an on
going educational process to make people aware how
wafer should be handled and used in these situations.
Prevention of pollution of the drinking water
sources by industrial waste and sewage is another area
needing urgent intervention.
The voluntary health sector has to address itself
to the many problems and issues the NDDCP may
overlook.
The section on "VHAI's Role in Diarrhoea care"
outlines our perception of how the voluntary health
sector can play a significant part in this effort.
What Constitu tes the Scientific Proof?
One topic I am frequently required to address is that of medical or scientific proof. Before I began this
study and had only the ideas, most of my colleagues told me that I would never be able to prove any
thing because there were too many variables involved. As I have accumulated more and more results, 1
still find that the question of scientific proof is a very difficult one. About a week ago I came across an
article which meant a great deal to me, and I would like to share it with you.
The article was about a psychiatrist who was doing some rather unorthodox work with schizophrenic
patients approximately twenty years ago and was obtaining some very good results. Because of the
nature of his techniques, however, his colleagues were reluctant to listen to him. He wrote approxima
tely ten articles on the subject, but their standard response was, "Well, you haven't really proven
anything." So he continued his work and wrote about ten more articles, and people continued to say
the same thing. He began to wonder just what it is that constitutes scientific proof. He did still more
work and published more papers, with the same result. He became determined to investigate thoroughly
this question of scientific proof.
Being the editor of a psychiatric journal, he decided to hold a symposium on the subject. He wrote letters
to several leading scientists, asking their participation in a study to determine what constitutes scientific
proof. The first reply came from a man who sent a very short note: "The question," he wrote, "is much
too difficult forme." He went on to say, briefly, that he doubted that he could make a significant
contribution to so complex an issue.
This answer was more than the humility of a great man; it was more than the reflection of scientific
honesty. It was at the root of a great man's whole philosophy of being. The letter was signed, "Albert
Einstein."
Source : The Holistic Health Handbook Berkeley Holistic Health Center AMD/OR Press Calif., USA
1978 : 480 pg.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
49
Controversies in ORT
After the final no, there comes a yes. And on that yes, the
future of the world depends.
—Wallace Stevens
One of the major controversies surrounding ORT
relates to the use of prepackaged ORS packets, pre
pared commercially or by organisations like the WHO.
Those in favour of the ORS packets, would like to see
them incorporated as the backbone of diarrhoea care
as a matter of policy. The arguments in favour of this
line of thinking run as follows :
1.
ORS packets are scientifically prepared and
are a complete formula.
2.
Ecor.omies of scale due to production in mass
quantities would reduce unit costs and with
large scale marketing and wide distribution,
accessibility could be increased as has been
done in Indonesia and the Honduras.
3.
Less chances of mistakes when preparing the
solution.
4.
Less chances of contamination.
5.
Less effort required on the part of the mother
preparing the solution.
6.
Greater acceptability because of third world
people's faith in western medicine and packa
ging does just that.
diarrhoea episodes. For just 10% of the worst
diarrhoea episodes, 280 million packets would
be required.
2.
Use of pre-packaged formulae increases the
dependency of the people for health needs on
outside agencies, government or voluntary.
3.
Moreover their stamp of authority ("prepared
by WHO", etc.) inhabits a serious conside
ration of local low cost options.
4.
They would cost much more than these local
options. Commercial preparations cost any
where between Rs. 5 to Rs. 6.45 for a 1-litre
solution.
5.
If adopted as a matter of policy, they would
encourage the flooding of the drugs market
with costly, irrational, unstandardised commer
cial packets, with pack-information that would
be inadequate or misunderstood by a majority
of the consumers.
Multinational companies have already been in
volved in the supply of ORS packs to UNICEF, WHO,
USAID funded programmes. With their large econo
7. With the replacement of bicarbonate with mies of scale they have been able to supply them at
sodium citrate, it can be safely kept for long lower prices, inhibiting internal production and sales in
periods, even in tropical areas.
third world countries by national producers. This has
However rosy this picture may appear, there are subs been some source of embarrassment for governments
as well as the international agencies. In Bangladesh,
tantial arguments against the packets too:
the offer by Gonosasthya Pharmaceuticals (G.K.'s
1. Inadequate production and availability. There
is just not enough production for the packets to
be widely available: In 1980, there were about
1400 million episodes of diarrhoea amongst
the 460 million under-fives of the world. This
would have required 2800 million packets
(i.e. 2 packets per episode). Inspite of plann
ing and the high priority given to health in
most developing countries, not more than 40
million ORS packets will be produced in 1983.
These can deal with merely 2% of the total
50
health for the millions oct./dec. 1983
Controversies in ORT
drug unit) to UNICEF for the production and distri
bution of ORS packets with adequate quality control,
was refused. Closer home, IDPL and other public
sector enterprises are unable to supply adequate
numbers of packets.
Hence if the decision is to be made in favour of
the prepackaged formula, one has to fall back on one
or more of a variety of unsatisfactory answers :
* Continue to buy from the Multinationals, through
international organisations like WHO.
* Ensure that national, public or private drug
companies produce ORS packets at reasonable
prices and in adequate quantities.
* Allow hospitals, health centres and community
health programmes to produce low cost packets
locally.
JEEVAN JAL
ORAL REHYDRATION POWDER FOR
DIARRHOEAL DISEASES
Mix the whole content with one litre of fresh
drinking or previously boiled and cooled
water. Administer orally approximate quantity
equivalent to the body fluid lost or as much
ae desired by the patient or as directed by
the Physician.
Each sachet contains the equivalent of:
3,5 g
©odium Chloride
1.5 g
Potassium Chloride
2,5 g
Sodium Bicarbonate
20,0 g
Glucose anhydrous
DO NOT BOIL SOLUTION
In any case, without the motivation to ensure the
use of Oral Rehydration, the mere presence of ORS
packets on the market shelf would not mean much.
The major arguments against the use of home-made
salt and sugar solutions are based on questions related
to effectiveness, safety, availability and accuracy of
measurement of weight and volumes of ingredients.
There are arguments and evidence to show that
in each case the doubts are misplaced and we can
consider each question separately :
Effectiveness : Studies in Bangladesh have
shown that salt sugar solutions are as effective in
treating dehydration as pre-packaged formulae. Simi
larly studies in Egypt show that in similar conditions
infant mortality could be reduced by say 50%. Where
complete formula ORS was available from commercial
sources, or in clinics, child mortality rates did not
change significantly. In spite of distribution of the
packets in 6 villages (in Egypt) no difference in diarr
hoea deaths compared to controls was found. Prof.
Wong Hock Boon's rice water study is yet one more
example of homo prepared ORS proving superior to
the commercial packets.
Safety : The safe concentration of sodium is con
sidered to lie between 40-120 milli mols per litre. In
the various studies quoted above, biochemical analysis
of about 1000 mixtures indicated that over 90% of
the illiterate mothers trained to prepare ORS were
doing so with adequate competence. The studies,
pait of the programme in Bangladesh and Egypt, have
shown that the safe limits are maintained in most
cases.
HEALTH FOR THE MILLIONS OCT. I DEC.
1933
Availability. There is no denying that there are
problems regarding availability of sugar in remote
areas, spacially in mountain areas. In Nepal, apparent
ly, sugar is not found in more than half the homes.
Though substitutes for white cane sugar are available
in some areas in the form of Khandsari sugar (impure
jaggery), beetroots, dates—carbohydrate substitutes
like rice conjee, barley water, sago, etc. are the only
real alternatives. However it is unrealistic to imagine
that where there is a problem regarding the availa
bility of sugar and salt, a ccnstant supply of ORS
packs will always ba maintained.
Accuracy in preparation. Difficulties in measur
ing fluid volume, salt and sugar definitely do exist.
With proper training, demonstration, repetition and
supervision these problems can be surmounted as has
been done in Bangladesh. Recent studies in CMC,
Vellore, have shown no significant difference in ORS
prepared by the pinch and scoop method and by us
ing standard plastic measuring spoons.
Most diarrhoea cases occur in homes with often no
easy access to health facilities. Promoting self-reliance
and self-sufficiency in families and communities is the
single biggest advantages. Associated with effective
results this further strengthens faith in home based
ORT. It is accepted that on an average around 10% of
51
Controversies in ORT
all diarrhoeas end in dehydration and of these 2%
require I.V. fluids. With early administration of ORT,
even these 2% can be prevented from needing hospi
talisation, thus cutting down costs of medical care.
The study in Bangladesh showed that of 3000 hos
pitalised patients studied over a period of 2 years, 95%
did not require I.V. fluids, and that use of ORT could
have avoided hospitalisation. Early ORT, even if it is
an incomplete formula, replaces lost fluids and pre
vents dehydration, keeps bowel enzymes active and
The PATH ORS Tablet
The PATH ORS tablet represents a dosage form
which was developed to enhance the distribution of
ORS. The amount of rehydration fluid needed for a
single episode of diarrhoea is often more than 1 but
less than 2 litres. However, for each bont out of diar
rhoea during the entire episode, the infant often drinks
about 150 to 200cc of ORS fluids. The unused portion
of the entire one litre very often is contaminated or
wasted. Also, one litre containers may not be readily
identified and available in some countries. The tablet
form may also be easier to handle by the end-users
and for distribution in the health network.
The present tablet is formulated to make 150 cc of
rehydration solution. The tablets are about 1-1* in
diameter and weigh roughly 5 grams; therefore, they
are unlikely to be accidently swallowed by children.
According to PATH the dosage of tablets could
be adjusted to meet the particular needs of each coun
try's rehydration program. Also, natural colouring
could be incorporated to enhance the acceptability of
the tablet. At present, they propose to pack strips of
Opportunity
Kurji Holy Family Hospital would like to sponsor a
student to the Nurse Anaesthesia Course: ''Will sponsor
a nurse : female, male, lay or religious with minimum
qualifications of Grade A nurse. Applicant should have
working knowledge of English and preferably some
operating theatre experience as a graduate nurse."
Also the sponsored student will have the oppor
tunity of working under an American trained doctor in
Anaesthesia. Certificate will be given by Voluntary
Health Association of India under a course plan recog
nised by the Indian Nursing Council. Please apply to;
Sr. (Dr) Fedes Copiaco, Anesthesia Department, Kurji
Holy Family Hospital, P.O. Sadaquat Ashram, Patna,
Bihar-800010.
52
prevents malabsorption of nutrients.
Switching over
from doctor-drug-dispensary
dependance to home based ORT is a simple inexpen
sive first step towards revolutionary changes in social
behaviour. A simple salt and sugar solution in the
hands of a mother with continuous health education,
backed by a balanced electrolyte solution in the hands
of the health care provider is a viable and most effec
tive way of reducing child mortality.
eight tablets in a 150 cc container. The formula used
for the oral rehydration tablets is a slight variation
from that recommended by the World Health Organi
sation in that sodium bicarbonate has been replaced by
sodium citrate which results in a tablet which is much
more stable over extended periods of storage and
which will disintegrate within 1--} to 2 minutes. PATH
is presently conducting stability studies to identify the
optimal packaging (both format and material) for the
tablet.
PATH is also developing support materials, such as
appropriate labels and package inserts, to ensure the
proper use of oral rehydration salts. PATH has deve
loped a pictorial technical pamphlet describing the
proper administration of ORS. They are extending the
development of these technical support materials to
several Asian countries :
For more details :
PATH
Cana! Place
130 Nickerson Street
Seattle WA
USA 98109
Do You Know
WATER
70% of India's Rural Population has no access to
safe drinking water. Out of this 160 million people
spread over 200,000 'Problem' villages face an acute
scarcity of drinking water according to the latest
Government data.
WATER-BORNE DISEASES
Two-thirds of all illnesses in India are related to
water-borne diseases such as typhoid, jaundice,
diarrhoea, dysentery ar.d cholera. This results in
economic loss of Rs. 200 crores a year in rural areas
because of loss of work days and productivity.
health for the millions oct./dec. 1983
HEALTH FOR THE MILLIONS OCT./DEC. 1 9 8 3
A RANGE OF REHYDRATION METHODS FOR CHILDREN WITH DIARRHEA
intravenous
solution
(I.V.)
factoryprepared
oral solution
factory-prepared
packets of
‘rehydration
bags with salts,
prepared at the
health center
MORE DEPENDENCY
control in the hands
of institutions and
professionals
ADVANTAGES AND DISADVANTAGES
Control and responsibility mainly in the hands of professionals,
institutions, and drug companies
Measurements more precise and ‘controlled’ (at least in theory)
More magical; acceptance may be quicker but with less understanding
More dependency—on high technology, on outside resources, on
centralized services, and on local and international politics
More expensive
homemade drink
made with plastic
measuring spoons
homemade drink
made with spoons
found in the
homemade drink
made with
homemade
homemade drink
with salt & sugar
measured with the
fingers or by
another traditional
way
___________________________ ► MORE SELF-SUFFICIENCY
control in the hands
of the family
ADVANTAGES AND DISADVANTAGES
Control and responsibility mostly in the hands of the family
Measurements less precise, less ‘controlled’
More practical and easier to understand
More self-sufficiency; uses local resources (whatever is available in the
home or in stores)
Cheaper
X
Harder to gather data on, and prepare statistics about
Easier to gather data on, and prepare’Statistics about
Reaches fewer people; supply often uncertain and inadequate
Sometimes causes delay in treatment, because special materials have to be
obtained; effect is more curative than preventive
Reaches more people; supply is local and almost always available
Treatment can begin at the first sign of diarrhea; more preventive than
curative
Focus is on materials and supply (so cost goes up each year)
Focus is on people and on education, so the people’s capacity for self-care
increases over the years (cost goes down)
May give better (safer) results for individuals treated in time, but has worse
results overall since many children never receive the liquid, or are given it
too late
May be less safe in individual cases due to the possibility of errors in
preparing or giving it, but it probably saves many more lives-since it
reaches more children more quickly
Source : Helping Health Workers Learn : David Werner and Bill Bower Page 15-13.
Cost effectiveness of the different options available
and situations in which they may be appropriate.
Plan
Advantages
Disadvantages
Situation
—- effective even for severe cholera
— standardised
— highly visible and identifiable
— effective for cholera and mild
diarrhoea (credibility because
it is WHO recommended).
— more expensive
— ingredients may not be
locally available
— can lead to hypernattemia
if used incorrectly.
effective for a health
system reaching the bulk
of the population.
Prepackaged WHO formula
with sucrose
— may cost less
— sucrose may be more readily
available.
— less effective for
severe diarrhoea
— may increase vomiting
— ineffective if sucrose
deficiency develops.
effective for a health
system reaching the bulk
of the population.
Local mixing using WHO
formula (spoon set)
— no dependence on central facilities
— no packaging costs.
— increased risk of error
— storage of ingredients
may be a problem.
effective for a system of
urban and rural clinics with
outreach to patients.
Home mixing using salt/sugar
formula (double spoon)
— reduced costs
— direct participation of community
and family
— no dependence on health system
— permits early institution of treatment
at home.
— not as effective as WHO
formula
— requires individual
instruction for use
— requires a proper sized
container in the home.
effective where majority has
no access to a centralised
health service but where
there is strong community
involvement in health.
HEALTH FOR THE MILLIONS OCT./d EC. 1983
Prepackaged WHO formula
HEALTH FOR the millions oct ./ dec . 1983
Plan
Advantages
Disadvantages
Situation
— Communities used to drugs would
find 'packets' more attractive and
and therefore acceptable.
— mystifies diarrhoea care
and puts the control in
the hands of an outside
agency.
— Creates unhealthy
dependence.
— Helping Health
Workers Learn
Local mixing using salt.sugar
— requires no packets, spoons
(no spoons)
or devices
— minimum investment
— encourages self reliance.
— measurement of ingredients
is more variable
— efficacy of solution cannot
be assumed
— requires instructions,
standardisation and frequent
follow-up.
effective where provision
of measuring spoons is not
practical.
— Risk of hyponatremia.
— Less effective in severe
diarrhoea caused by V.
cholera or E. Coli.
Effective where supervision
and surveillance is
impossible.
Any distribution scheme
— decreased risk of
using formula with lower
hyponatremia.
sodium content (eg. 60 meq/L).
Ref: Committee on International Nutrition Programs, Food and Nutrition Board, Assembly of Life Sciences, National Research
Council; National Academy Press, Washington D.C, 1981. pp. 12-13.
New Directions
International Conference on ORT Washington, D.C.,
7-10 June 1983
Lincoln Chen
Summary of proceedings
2.
The world's leading experts on ORT convened in
Washington, D.C., to examine strategies for combating
dehydration caused by diarrhoea.
Second, oral rehydration therapy is a simple and
effective method. It is economically affordable, selfsustaining, safe, improves access and self-reliance, and
is useful for diarrhoea of all etiologies in all age
groups.
The key speakers were James P. Grant, Executive
Director, UNICEF, and Halfdan Mahler, Director
General, WHO. The conference was sponsored by
USAID, UNICEF, WHO, and ICDDR, B.
Lincoln Chen, Representative of the Ford Founda
tion in New Delhi, presented the summary of proceed
ings at the closing session. An outstanding feature of
ICORT was the consensus achieved on five crucial
points relating to the nature and treatment of diar
rhoea. The agreed agenda for the future is the imple
mentation of ORT on a wide scale. The remainder of
his summary deals with eight issues fundamental to
achieving wide coverage.
3.
OR T, a safe and affordable method
ORT, an effective therapy with many advantages
Third, oral rehydration therapy can make a
difference—a significant difference—• not just theoreti
cally but practically in field settings around the world.
The experiences, reported at this conference un
equivocally confirm that oral rehydration therapy can
reduce mortality, sometimes dramatically, in com
munities, clinics, and hospitals; promote child growth
and sound nutrition ; lessen the morbidity burden ;
reduce hospitalisation attendance, duration of stay and
cost ; and generate ancillary benefits such as mini
mising the indiscriminate use of ineffective or harmful
drugs.
How does one summarise a conference that has
550 participants from 100 countries, 35 hours of pre
sentations and 46 scientific papers weighing over
3 kg ? The task is hazardous. A summary cannot be
comprehensive and risks repetition. The process is 4. A chemical composition based on established
scientific principles
necessarily selective, aimed at balance yet focus.
In the end this summary is merely one person's
effort. More important is the judgment of each indivi
dual participant and what we each fake from and do
after this experience.
Five points of broad consensus
The most outstanding feature of this conference has
been broad-based consensus, indeed near unanimity,
on several major points.
1.
The significance of diarrhoea
First is the significance of diarrhoea as a killer and
debilitator, particularly among poor and disadvantaged
children. This fact may seem obvious, but would not
have been so at similar gatherings even six years ago.
56
Fourth, the scientific principle underlying oral
rehydration therapy is well established and the basic
chemical composition generally accepted. The basic
ingredients are sodium, potassium, bicarbonate and a
suitable carrier substrate such as glucose. Among
these, appropriate concentrations of sodium and glu
cose are essential in all oral rehydration solutions.
Potassium and bicarbonate are also necessary ; their
absence in some solutions when used for severe
diarrhoea may lead to prolonged acidosis and hypoka
lemia. But the practical implications remain unclear.
As with many other issues, we repeatedly face the
difficult trade-off between optimising technology while
maximising access, use and impact under many
different circumstances.
HEALTH FOR THE MILLIONS OCT./dEC. 1983
New Directions
5.
The agenda : how to do it
Fifth and most importantly, the agenda is not what
to do, but how to do it. Most action programmes
today are pilot, demonstration, or experimental.
Several are large-scale. But the challenge remains :
how to propagate the use of this new technology in
villages and slums where it is needed. One point that
emerged was that access to this technology is crucial.
People do have common sense and would readily
change their behaviour and use oral rehydration if the
technology
were demonstrably beneficial and
accessible.
Eight fundamental issues
The remainder of this summary discusses eight
issues considered fundamental in determining oral
rehydration access with effectiveness.
7.
Insufficiency of ORT alone
Rehydration alone is insufficient. Diarrhoea is both
an infectious and a nutritional problem. Oral rehydra
tion as a response, therefore, must necessarily be nutri
tionally enhancing. This may involve nutrient enrich
ment of the electrolyte solution, promotion of breast
feeding, sound feeding practices during diarrhoea and
convalescence, and dealing squarely with the vexing
problem of prevention—personal and household
hygiene, wafer, and sanitation.
2.
Importance of training the mother
3.
The role of the health system
The health system should introduce oral rehydra
tion in the field and in clinics and hospitals, backed
wherever possible by intravenous fluids. The health
system should also undertake the production and dis
semination of packets. Packets contain an optimal
composition of salts, but their distribution depends on
strong logistical support.
At the periphery of the health system, community
field and clinic-based workers should receive adequate
training and supervision. In hospitals, doctors need
reinforcement in the use of oral rehydration, backed by
intravenous fluids. Health facilities may be used as
training centres, aimed at transferring skills to the
community. Diarrhoea and oral rehydration should be
emphasised in medical school curricula. Proper appli
cation of oral rehydration in hospitals can contribute
to an overall reduction in diarrhoea mortality, and the
goal of eliminating dehydration deaths in hospitals is
an achievable goal worth of implementation. Finally,
recent studies have demonstrated the many advan
tages of oral rehydration in hospitals of developed
countries. Oral rehydration therefore should become a
global effort. Because doctors are influenced by the
practices of their elite professional counterparts, the
legitimisation and use of oral rehydration in hospitals
in the developed countries should receive high priority.
4.
The links between the health system and the home
Linkages between the home and the health system
The mother is a partner in oral rehydration delivery.
are important. When considered together, they face
In child care, the mother possesses many advantages, the challenge of complementarity with synergism and
not the least of which are her motivation, her constant minimisation of conflict and duplication. Regrettably,
presence, and her capacity to undertake immediate and in most rural areas in the developing world duplication
timely action. The mother is the first-line responder is rarely the problem. Home-based therapy is an ap
to all children's illnesses, including diarrhoea. When propriate initial response for all diarrhoea cases. The
adequately trained (particularly through direct demons health system's capacity to deal with referred of severe
tration), mothers can mix salts and fluids into safe and cases should be strengthened. An unresolved linkage
effective home-based solutions using either packets or issue between the home and the health system is the
local ingredients with locally adapted mixing methods. consistency of the oral rehydration message. Some
Home-based programmes require an understanding of programmes advocate identical oral rehydration solu
the user's perspective, the constraints that a mother tions for all facilities—from home to hospitals. These
faces, and the resources at her command. Interven may be packets or local mixtures. Others see a conti
tions must aim at supporting a sustained, interactive, nuum between home-based local mixtures, packet
communicative relationship with the mother. She is distribution and oral and intravenous fluids in ad
particularly important if the focus shifts from exclu vanced facilities.
sive treatment of dehydration to integrated dehydra
5. Three contrasting views on implementation
tion and nutrition interventions because nutrition can
structures
not be improved without the mother taking an act ive
role.
Another issue is integration. Should the priority be
health for the millions oct./dec. 1983
57
New Directions
oral rehydration versus comprehensive diarrhoea
management versus primary health care versus socio
economic development ? There are at least three con
trasting views. One view : oral rehydration addresses
only a single problem. The development of a vertical
operational structure is not cost-effective, is counter
productive, and detracts from the long-term streng
thening of primary health care. Another view : oral
rehydration itself is of high priority, feasible, and costeffective. Separate structures are justifiable where a
primary health care infrastructure is either absent or
underdeveloped. A third view : oral rehydration versus
primary health care is a false dichotomy. Everyone
concurs that primary health care is the ultimate goal;
the means in terms of steps, timing, and paths may
and ought to vary depending upon local circumstances.
Oral rehydration therapy is an entry, a rallying point
for primary health care. Because it is effective, if can
help cement confidence between a health system and
the people it serves. Primary health care itself advo
cates prioritisation, cost-effectiveness, self-reliance,
and community participation. When these criteria are
applied, oral rehydration comes out near the top of the
list. If the dichotomy is moved from abstraction into
operations in the field, the differences between the two
diminish.
A final, often neglected, yet important and relevant
question is : does the health care structure—whether
oral rehydration or primary health care—have the capa
city to change, to grow, to mature over time in res
ponse to problem-solving ?
6.
The need for multiple support structures
purposes ? Social marketing could generate demand
and increase availability of oral rehydration salts.
Caution, however, should be exercised in blending
together the profit and social motives into an effective
instrument for improving health.
7.
The need to develop new attitudes in health
systems and in the community
Oral rehydration basically consists of changes of
attitude, behaviour, and practices—among mothers
(discussed earlier), decision makers, governments, and
the public at large. All must be convinced of the
human, practical, and economic imperatives of oral
rehydration. The most important group may be the
health professional, especially doctors. Doctors
maintain technical and often administrative control
over health technologies and systems. They can be a
barrier of non-cooperation, or a significant source of
support to the promotion of oral therapy. The propa
gation of oral rehydration would be difficult without
the backing of the medical profession. Doctors must
be shown that oral rehydration is appropriate and
effective. Their interest in diarrhoea as a major public
health problem should be encouraged.
Changes of attitude, behaviour, and practice can be
stimulated and reinforced by sound communication
and mass media progammes. The radio, newspapers,
bill-boards, and materials for the illiterate can exert
powerful influences. Much creative work can be done.
Our ability to generate technical change appears to
surpass by far our capacity to understand and direct
social and behavioural change.
Access to oral rehydration requires several channels
and multiple support structures, and to have such re
quires moving beyond the health system. A single
path linking mother and child to health system field
worker to clinics and hospitalsis fragile, incomplete,
episodic, and even under optimal circumstances may
never provide complete access. Parallel delivery struc
tures need to be strengthened, amongst which are :
primary schools, religious bodies, non-governmental
and voluntary agencies, community groups, traditional
health systems including midwives and healers, and
the private commercial sector, such as pharmacies. The
private sector has been successful in generating de
mand and making available a wide range of goods—
some useful, some less so, and some harmful. Why
not direct this powerful force towards socially useful
58
HEALTH FOR THE MILLIONS OCT./DEC. 1983
New Directions
8.
The need for critical evaluation and basic research
Policy, planning, research and evaluation. An im
mediate need is the development of simple, reliable
indicators and methodologies to measure, analyze, and
interpret the diverse oral rehydration field experiences
that are taking place throughout the world. Some label
this as action research or operations research : it may
involve in-depth qualitative case studies or rigor
ous quantitative methods. These methods should
focus not only on input (number of workers) or
activities (number of packets distributed), but
also on cost (time and money) and output (nutri
tional status, morbidity, mortality). Critical exa
minations of performance are essential as oral
rehydration activities proliferate. As their diversity
multiples and their scale expands, we will require a
systematic capacity to scrutinise, build upon, and
generalize on what works. As importantly, we will
need to debunk and discard what does not work. And
we will need to understand why and how. A lesson from
history is appropriate here. It took 130 years from the
first attempt at intravenous rehydration until we reach
ed a stage when it has matured into a scientifically
accepted technology. In our enthusiasm for imple
mentation, let us not allow another century to lapse
before we can accumulate and develop our knowledge
base to bring oral rehydration effectively to the people.
Other research is also needed, such as on amino
acid fortification to enhance absorption and cereal
based solutions, using locally available salts and
nutrients. Some examples are rice powder, carrot soup,
and fluids made of other local cereals. The advantages
of these solutions are low osmotic lead, decreasing
diarrhoea volume and duration, and increased acces
sibility and cost-effectiveness. These should be sub
jected to field trials in real world situations as soon as
possible. There is also no substitute or short cut for
basic research. Basic research, using modern scientific
methods, is needed to delineate the mechanism of
diarrhoea. Pharmacological agent(s) to halt diarrhoea
should be developed. New and effective vaccines are
needed. One lesson about basic research (which the
ICDDR,B experience illustrates) is that we are today
harvesting the benefits of two decades of carefully
planned and nurtured basic applied research invest
ments. Such support is weak and less productive if
the research is episodic or ad hoc. The ICDDR,B ex
perience also teaches us that we need to apply our
health for the millions oct./dec. 1983
most sophisticated scientific capabilities to the right
problem in a context where the problem is most
prevalent.
Adapting approaches to local needs
Much progress has been made. Much, much more
needs to be done, and done soon. Oral rehydration
therapy is increasingly capturing the imagination of
the policy makers, the scientists, and the public. It has
gained legitimacy, even in the medical profession I
Some caveats are indicated, however. Oral rehy
dration is not a panacea. While recognising its impor
tance, we must avoid oversell. Diarrhoea is only one
—granted, important—disease amongst several major
health problems. Diarrhoea is also both a symptom of
and a contributor to poverty and underdevelopment.
Oral rehydration therapy should not be used as an
alternative or palliative to avoid addressing the funda
mental problems of poverty. Finally, choices must be
made. Conferences often conclude that everything
should be done. But we cannot do it all. Choices and
trade-offs will need to be made, at all levels. Especi
ally relevant to field application is the adage : the best
is the enemy of the good.
The premium today is on pragmatism. What works ?
Progress will depend upon local ingenuity, adapta
tion, and what I call "creative health entepreneurship".
Approaches to oral rehydration will necessarily vary
between different communities in different countries.
The mix of approaches will differ, as decisions should
be made locally. The process of making things work
will call for learning by doing. This needs fostering
and can be promoted through dialogue, exchange of
ideas, and sharing of experiences. This conference has
made a significant contribution to this purpose.
Source: "assignment children" 61/62, 1983—A
Child Survival and Development Revolution"
Wanted
One female doctor with MD in CH/MPH/DPH or
MBBS. The person should have two to three years
of experience in health care programmes. Apply to
The Medical Superintendent St. Stephen's Hospital—
Tis Hazari, Delhi-110054.
59
VHAl’s Role in Diarrhoea Care
Even as the clouds of controversy settle on
the various issues involved in diarrhoea care,
one thing that emerges clearly is the increas
ingly important role the voluntary sector would
have to play if any success is to be achieved in
the anti-diarrhoea campaign. This role would
have to range from assimilating the correct
ideas to community education to campaigning
against dangerous anti-diarrhoeals and will
have to encompass training, research and imp
lementation. Below, point-wise, we at VHAI
have enumerated the kind of intervention we
envisage making in this campaign.
There are a large number of private, voluntary organisations
active in the health field all over the country. Their services
and support would require to be utilised and intermeshed
with the governmental efforts, in an integrated manner.
—National Health Policy
Government of India
1.
Study and analysis of the various diarrhoea related
studies inside and outside India which have practi
cal implications for people in the field.
2.
Collation of learning experience of different com
munity health programmes and hospitals in regard
to diarrhoea.
... Demand unbiased authentic information about
all anti-diarrhoeal drugs
... Demand a ban on hazardous and irrational
drugs like chloramphenicol-strepfomycin com
binations, clioquinols, diphenoxylates.
7.
... incidence of diarrhoea in their area
... interventions made by the programmes
"Medicines are not enough to treat Diarrhoea.
Oral Rehydration is most important"
... impact of those interventions
... beliefs related to the causation and manage
ment of diarrhoea
... remedies and rehydration
traditionally in the area.
3.
4.
therapies
(WHO Formula and how to prepare if should be
given pictorially and in regional languages for
consumers and registered medical practitioners
many of them who do not know English).
used
Collation of diarrhoea-related educational material
from different sources and their modification (if
needed) and dissemination e.g., Diarrhoea Dia
logue by AHRTAG, Glimpses from ICDDR,B
etc.
8. Campaign for standardisation of commercial pre
parations of Oral Rehydration Solution in keeping
with WHO recommendations, with clear illustra
tions and in regional languages :
... how to prepare solution in limited amounts as
and when needed.
Preparation of low cost educational material for
... health personnel
... non-healfh activist groups
... when to discard left over solution
... dangers of preparing inaccurate solution.
9.
Work for the involvement of consumer groups,
women's groups, development workers, educatio
nists and others involved in people's Health
Movement—with "Early Diarrhoea Care' as the
basic slogan.
10.
Organisation of workshops and seminars for field
level personnel—-"'Prevention, Assessment and
Rational Care of Diarrhoea". Focus on ORT and
identification of those diarrhoea cases (eg. ameobiasis, gardiasis, bacillary dysentery) which require
specific treatment.
... people, especially mothers and school children.
5.
Identification
people :
of resource centres and resource
... sharing information
... skills for streamlined rational diarrhoea care.
6.
Campaigns :
... Continuation of the coordinated campaign
against the misuse of antidiarrhoeals.
60
Campaign to make the following instructions
compulsory in packaging and advertising literature
of all anti-diarrhoeal drugs :
HEALTH FOR THE MILLIONS OCT./dEC. 1983
VHAI's Role in Diarrhoea Care
11.
Preparation of adequate materials and tools :
Research Priorities for the Future
... to measure correct quantities of ingredients
for ORS and to train others in preparing it.
Specific Topics for Future Research on
Diarrhoeal Disease^
... for identifying cause and type of diarrhoea
from general appearance of stools
1.
... simple lab tests for health personnel in the
field
Behavioural, sociocultural and anthropologic deter
minants of food and water handling and hygiene in
the causation of diarrhoea.
... different
water
12.
methods
of disinfecting drinking
Propagation of indigenous methods of low cost
sanitation e.g.z as evolved by Safai Vidyalay,
Ahmedabad, Gujarat; Sulabha Shauchalaya, Patna,
Bihar.
Etiopathogenesis and epidemiology
— Synergism between parasites and accepted agents
of diarrhoeal disease, especially with regard to their
combined impact on nutritional status.
— Age-related changes in susceptibility to infectious
diarrhoea, (eg. maturation of local intestinal de
fense, both antigenspecific and nonspecific, recep
13. Through State VHA's and other Organisations
tors on epithelial cells).
help, people avail of the government facilities
meant for them. e.g. funds available during the — The incidence and nutritional cost or mixed viralbacterial infections of the intestine.
water decade for drinking water sanitation.
14.
Collaborating with other like minded organisations
involved in health work.
15.
Undertaking directly or indirectly some specific
research studies :
... Comparative study of various traditional oral
rehydration therapies and also widely accep
ted and tried modes of diarrhoea treatment,
traditional and modern.
... Study of the modifications required in the
traditional methods to make them more effec
tive. e.g., addition of certain electrolytes in
jeera (cumin seed) water or sonf (ani seed)
wafer.
... Determine the effect of sulphurisation and
addition of lime in the treatment process of
Khandsari (unpurified sugar).
••• Methods of disinfecting water; including role
copper vessels, earthen pots as compared to
plastic and other metals.
16.
Ensure that the public sector pharmaceuticals
e.g. IDPL produce adequate amounts of low cost,
standardised and easily available ORS packets
with adequately long shelf life.
health for the millions oct./dec. 1983
— Investigation of the nature and nutritional impli
cations of environmental enteropathy (tropical
sprue, etc.).
— Assessment of the magnitude and impact of chronic
diarrhoea.
2.
Nutritional impact
— What is the nutritional cost of apparently asympto
matic, unrecognised infection with enteric orga
nisms ?
— What are the catabolic effects of noninvasive micro
organisms associated with diarrhoea ?
— How does one distinguish the nutritional effects of
diarrhoea in terms of the impact of infection per se,
and of the secondary complications due to disease
(eg. sugar intolerance) and Iatrogenic factors
(dietary advice, drugs).
3.
Outcome
— What is the impact of diarrhoea associated nutri
tional deficits on growth and development ?
— What are the effects of the diarrhoea malnutrition
complex on physical activity and work perfor
mance ?
61
VHAI's Rote in Diarrhoea Care
— To what extent does nutritional deficiency con
tribute to diarrhoeal disease ?
4.
Interventions
— The development and evaluation of weaning foods
manufactured by village-level and home technology
according to regional and cultural patterns.
— The study of various practical aspects of oral re
hydration therapy (eg. ingredients including sub
strates, delivery, local sources of various ingre
dients such as potassium evaluation of effective
ness, impact of rehydration on appetite and food
intake).
— Evaluation of traditional folk medicines.
A good booklet on the cause and the treatment of
diarrhoea with effective drawings and flow charts on
the management of dehydration in diarrhoea.
2. Oral Rehydration Therapy : An Annotated
Bibliography.
Pan American Health Organization 1980, 116 pp
The sections are : history, clinical trials composition,
impact and implementation. Also an author and
country index.
3.
VHAI ; 1983, 28 pp.
An Illustrative booklet with photographs and line
drawings.
Journals
1.
— Management of chronic diarrhoea.
Specific areas in home based ORT requiring
research :
1.
Short, quick survey in different regions of a country
to assess existing cultural beliefs, perceptions and
practices related to diarrhoea, its treatment as well
as food and fluids specially given and avoided
during diarrhoea particularly for children.
2.
Cost effectiveness studies comparing home based
ORT, ORS packets, and I.V. fluids.
3.
Research on locally available edible materials, rich
in nutrients, which can provide sugar and salt
efficiently eg. rice powder.
4.
Assess the role of voluntary organisations and
women's organisations in promoting a widespread
campaign on home based ORT.
5.
Studies on best health education approaches to
teach mothers in different regions.
References :
Extract from : R.K. Chandra Et Al from "Diarrhoea and
Malnutrition" edited by Lincoln Chen
List of Materials on Diarrhoea
Books (ReportIBibliography)
1. Treatment and prevention of Dehydration
in Diarrhoeal Diseases
(a guide for use at the primary level) World Health
Organization, Geneva 1976, 31 pp.
62
Better Care During Diarrhoea
2.
GLIMPSE Newsletter
International Centre for Diarrhoeal
Disease Research, Bangladesh
G.P.O. Box 128, Dhaka 2, Bangladesh
Diarrhoea Dialogue (quarterly)
AHRTAG, 85, Marylebone High Street,
London W1 M 3DE, U.K.
“Other Publications"
1. There are Solutions—Brochure published by Life
Support and Technologies International
4760 Calle Camarada
Santa Barbara, CA 93110.
2. Oral Rehydration in the Village : Eight Myths.
Academy for Educational Development
1414 22nd Street N.W.
Washington D.C. 20037.
3. Oral Rehydration Therapy : Information for
Action Resource Guide.
World Federation of Public Health Associations
P.O. Box 99, 1211 Geneva 20, Switzerland.
4. Diarrhoeal Diseases Control —Examples
of
Health Education Materials—WHO.
5.
Diarrhoeal Diseases Control—WHO.
6.
Appropriate Nutrition Intervention through
Appropriate Low Cost Technology—A case for
ORT and Measles Immunisation.
Dr. Valerian P. Kimati, Regional
Programme Officer, Primary Health Care.
7. Population Reports Series, UNICEF No. 2—ORT
for Childhood Diarrhoea.
(Contd. on page 64)
HEALTH FOR THE MILLIONS OCT./dEC. 1983
BOOK REVIEW
Diarrhoea and Malnutrition
Interactions,
Mechanisms,
and
Interventions.
Edited by Lincoln C. Chen and Nevin S. Scrimshaw.
Plenum Publishing Corporation, New York, in co
operation with the United Nations University, 1982.
Quantitatively, diarrhoeal disease predominates Chen in table 1 of chapter 1 on Diarrhoea and Mal
over all other non-dietary causes of malnutrition in nutrition. Continuing breast-feeding and giving food
low-income countries. It has been established that and rehydration even in the presence of vomiting and
the nutritional status of a child is usually as much the diarrhoea involve changing traditional ideas, attitudes,
product of infection as of diet1; and studies in the and practices not only among lay people but among
Gambia have indicated that diarrhoeal illness contri doctors themselves.
butes almost exclusively to the non-dietary element in
This book explains very clearly the mechanisms
failure to grow2. Diarrhoea and Malnutrition— the pro
ceedings of a conference on the Interactions of Diar involved in producing malnutrition in diarrhoea, with
rhoea and Malnutrition held in Bellagio, Italy, in May ample proof from scientific and clinical studies. The
1981 under the sponsorship of the Rockefeller and mechanisms that precipitate malnutrition in diarrhoeal
Ford Foundations, the United Nations University, and disease include loss of appetite, the witholding of
the International Centre for Diarrhoeal Disease Re food, and the inappropriate use of certain foods in
search, Bangladesh—provides information on the treating the patient, the catabolic effect, direct loss of
most recent advances in understanding and answering nutrients in the stool, and intestinal malabsorption.
some of the long-standing problems on this subject.
A wealth of new knowledge on malabsorption of
carbohydrate, protein, and fat in relation to the causa
Paradoxically, physicians for a long time have
tive organisms in diarrhoeal disease is presented. The
made the malnutrition produced by diarrhoeal disease
fact that there is usually increased appetite and in
worse: up to the mid-1970s doctors were being
creased food intake during convalescence from diar
taught that the initial treatment for diarrhoea was to
rhoea to compensate for body weight loss and for
starve the patient, and there are those who are still
catch-up growth in children is emphasised. The major
following that practice. Thirty-two years ago Arthur
fact has now come to light that the dietary protein
Chung and his colleagues, working in the Children's
allowance given by FAO/WHO in 1973 did not
Medical Service of Bellevue Hospital in New York and
consider the extra dietary protein required under condi
at the University Children's Clinic in Bratislava,
tions of repeated infections like diarrhoea in which
Czechoslovakia, must have been extremely frustrated
protein is always lost through the gut, and sometimes
and depressed when virtually all physicians regarded also through catabolic processes, in low-income coun
their idea of giving food during diarrhoeal episodes as tries. It is because of these considerations that scien
something of a medical heresy. Today, a generation tists such as Roger Whitehead, supported by clinical
later, it is recognised that Chung was correct : and laboratory studies of other independent workers,
children fed throughout the acute phase of watery recommend a 30 per cent increase in calories and a
diarrhoea absorb substantial quantities of nutrients, 100 per cent increase in protein (4 gm/kg/day) to opti
demonstrate significantly better weight gain, and have mise repletion in young children depleted by infec
diarrhoea for a shorter time than unfed matched cont tion. This is why there is consensus that, in lowrols. This rediscovered insight is vital in low-income income countries of Asia, Latin America, and Africa,
countries of Asia, Africa, and Latin America, which where repeated diarrhoeal episodes in childhood are the
have 94.4 per cent of all the diarrhoeal disease in the rule, the recommended dietary allowance for protein
world occurring among children, as pointed out by should be 25-30 per cent above the 1973 FAO/WHO
health for the millions oct./dec. 1983
63
Book Review
recommendations to compensate for nutritional losses
during frequent disease episodes in order to maintain
normal growth and development.
On the question of definition of diarrhoea—which
can raise controversies-the authors define diarrhoea
as "increase in the frequency by two or more times of
the usual daily number of stools that are, in addition,
loose, extending over a period of 24 hours or more.
The presence of nausea, vomiting, fever, abdominal
cramps, dehydration or bloody mucoid stools is con
sistent with but not necessary for the diagnosis"
(chap. 16). The book strongly emphasises that the
correct therapeutic approach in the treatment of diarr
hoea is to use electrolyte fluids and food without
drugs. Much stress has been put on continuing breast
feeding during diarrhoea. The recommended thera
peutic approach is summarised in chapter 17, where
the authors say that "cereals, legumes, and other
locally available staple foods may thus become, in
proper quantities, the basis of a combined fluid, pro
tein-energy oral therapy for diarrhoea, a single anti
dote for the FEM-PEM cycle." Absolute poverty in
low-income countries is an important limiting factor in
most programmes intended to reduce diarrhoea, as
noted by Benjamin Torun in chapter 15.
medical undergraduates and post-graduates, practising
physicians, and public health specialists.
References
1.
Nevin S. Scrimshaw et al., in R.E., Olson, ed., Protein-Calorie
Malnutrition (Academic Press. New York, 1975).
2.
M.G.M. Rowland, T.J. Cole, and R.G. Whitehead, "A Quantita
tive Study into the Role of Infection in Determining Nutritional
Status in Gambian Village Children". Brit. J. Nutr., 37:441-450.
Reviewed by
Valerian P. Kimati, UNU-WHP Fellow and
Visiting Scientist, MIT/Harvard International
Food and Nutrition Policy Programme,
Incharge, Primary Health Care, UNICEF,
India.
(Courtesy: Food and Nutrition Bulletin, Vol. 4,
No. 2).
Social Audit
For more materials on Lomotil and Clioquinol (see
back cover taken from Social Audit's leaflet) please
write to :
Social Audit Ltd., Munro Place, 9 Poland Street
London WIV 3 DG U.K.
Cassette Available in English and Tamil
The book, compiled by highly competent scientists
Commentary for the slides—Feeding your Baby
in the field of applied research in malnutrition and
Prepared
by the Santhome Communication Centre
diarrhoea, delivers facts that are undisputable, as well
150' Lux Church Road
as indicating areas that need further research. Medical
Madras—600 004
and nutrition planners need to be made aware of the
relevant facts so that rapid action will be taken at Price : Rs. 45/- per Cassette
policy and operational levels to stop the abnormally
high morbidity and mortality caused by interactions of {Contd. from page 62)
diarrhoea and malnutrition. Asian, Latin American, and * Drug Diplomacy by Charles Medawar and Barbara
African countries should give high priority to the pre
Freese
Social Audit Ltd United Kingdom, 1982, 114 pp.
vention and control of diarrhoea, using the relatively
low-cost technologies suggested in the book (e.g, * Drug Induced Sufferings—
preparation and administration of oral rehydration fluid
Medical, Pharmaceutical and Legal
at home). These low-income countries can possibly
Edited by T. Soda,
seek goodwill and help from friendly developed and
Excerpta Medica,
industrialised nations to give them materials, money,
305 Keizersgrahi 1000 B C Amsterdam
and manpower support to achieve the global aim
P.O. Box 1126, 514 PP.
"health for all by the year 2000". Lincoln Chen and * Geneva Press Conference on SMON
Nevin Scrimshaw are to be congratulated for editing
Procedings—
and producing this comprehensive, well-written, use
April 28, 1980.
ful book aimed especially at stimulating and initiating
Published by Organising Committee of the Geneva
programmes that will lead to a reduced incidence of
Conference on SMON
malnutrition, particularly in low-income countries. The
54 PP.
book is highly recommended as essential reading for
HEALTH FOR THE MILLIONS OCT./DEC. 19S3
64
DIARRHOEA It can be dangerous
— don't take it lightly
Babies and young children.
especially between six
months and two years, are
susceptible! to diarrhoea.
Dirty surroundings, poor
personal hygiene and lack
of safe drinking water are
lately to blame.
Diarrhoea is not a single
disease. It is a symptom that
accompanies intestinal
disorders. Diarrhoea causes
loss ot vital body lluids and
salts. I hi! baby passes
frequent watery stools
which may be foul smelling
I hv baby may also vomit.
I he first response to
dian'hoea si lould be
immediate replacement ol
boiiy lluids This can be
done simply and
inexpensively, at home In a
glasslul.of boiled and cooled
water, add a pinch of salt
Mak<! sure this mixture is
not saltier than your tears.
Then add 2 teaspoons of
sugar. I’he baby may refuse
to drink this, but insist on
giving this mixture
frequently in small
quantities. Rice kanji or
coconut water can also be
given. If you fail to replace
the lluids lost in the baby, it
can lead to a dangerous
situation called
dehydration’.
Bottle-fed babies have
diarrhoea six limes
more often than
breastfed babies.
Breastfeed your baby
as long as you can—
even when Ihe baby
has diarrhoea.
Here arc some facts tlvat parents
must remember.
• Immediately give plenty of liquids to a child with
diarrhoea to avoid dehydration.
o Do not stop breastfeeding under any circumstances
o Continue normal feeding.
o Contact your doctor immediately, if the child s
condition does not improve within two days
• Prolonged dian’hoea can cause death.
So many different brands of clioquinol recommended
for the prevention or treatment of non-specific
diarrhoeas.
How does a doctor choose between them?
A brand of clioquinol from an unknown local firm?
Or Mexaform or Entero-Vioform - world leading brands
from a trusted Swiss name, CIBA?
The choice is immaterial. This is because all
brands have this in common: 'In the treatment of non
specific diarrhoeas, their benefits have not been
proven.
Their dangers clearly have.
Whatever the brand - with clioquinol there, is no
choice.
Thank you for not -prescribing it.
DEAR DOCTOR LETTERS
LIKE THIS?
h
■
This ‘Dear Doctor’ leaflet
puts patients first. It was prepared and I;
Social Audit and friends.
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