Is it right to sell ORS to poor people when they could make their own?

[Guest post by Jane Berry with technical support from Rohit Ramchandani]

We’re occasionally asked, sometimes quite assertively, why we are encouraging poor mothers and care-givers to spend what little cash they have on a Kit Yamoyo, which contains commercially produced oral rehydration salts (ORS) sachets, when a simple recipe of salt, sugar and water (Sugar-Salt Solution or SSS) can easily be fed to a sick child at home, to do the same job ‘for just pence’.

As so often is the case, the devil is in the detail. Assumptions about what is right or easy or appropriate for an illiterate mother or carer can’t be taken for granted. Is the SSS recipe really ‘simple’ for her? Does she have sugar and salt at home? Can the resulting nasty tasting (if life saving) mix really be easily fed to a sick child? And does it actually do the same job?

The discovery in the 1960s that salt and sugar are transported together across the small intestines through a co-transport mechanism, to address life-threatening dehydration has been called “potentially the most important medical advance of the 20th century.”[1] Homemade ORS solution or SSS was heavily promoted by WHO, UNICEF and lots of NGOs in community work the 80s and 90s – and it goes on to this day. UNICEF even came up with some very attractive measuring spoons.

UNICEF ORS Measuring spoons

At one point, we were going to put one of these spoons in our kit, with appropriate instructions. But you never see them nowadays (this set comes from a museum). Why?

People really get on their soap box about these questions. The Oxfam Handbook of Development and Relief (1995) says:

“ORT (Oral Rehydration Therapy) should not become dependent on the availability of a massed produced product, but should be part of common knowledge.”

And David Werner, who wrote ‘Where there is no Doctor’ (our ‘bible’ in remote Mpika in the 1980s) wrote 40 pages on the subject in 1997, along with David Sanders, in ‘Questioning the Solution: The Politics of Primary Health Care and Child Survival with an in–depth critique of Oral Rehydration Therapy’. If you are still with me, dear reader, you will be getting the idea!

The highly respected rehydrate.org has an SSS recipe; the equally respected DefeatDD.org mentions the ‘simple sugar and salt’ mixture. The bottom line is that any fluids and nutritious foods that you can get into a sick child are going to help. Continuing breast feeding is essential. And all of the ColaLife training materials emphasise that.

So, why are we trying to sell poor mothers a kit containing ORS sachets? Well, policy and good practice moves on, and WHO/UNICEF (among others) now say that while any oral rehydration is helpful, Low Osmolarity ORS – the kind we use – is ‘the gold standard’ and has ‘important clinical benefits’. Over to our Public Health Advisor, Rohit Ramchandani:

“While it’s important and useful for caregivers to know how to make homemade sugar and salt solution (SSS), ideally it’s something that would be used when an alternative is unavailable. Low-osmolarity ORS is clinically superior to 1/2 teaspoon of salt and 6 teaspoons of sugar in a litre of water, which comes with adverse risks of hypertonicity on net fluid absorption.

“Homemade SSS does not contain important ingredients like potassium chloride and trisodium citrate and there are important differences between what SSS and commercially formulated low-osmolarity ORS can do: it reduces stool volume, vomiting, and the need for unscheduled intravenous therapy, for example. This is not to mention the very important addition of Zinc to the treatment regimen co-packaged in Kit Yamoyo. Nonetheless, when ORS and Zinc are unavailable, SSS is an important alternative.”

It’s Rohit’s job to know the science, and the science seems to agree. A review of 205 papers published in 2010[2], to identify the efficacy and effectiveness of ORS and home fluids (RHFs), concluded: ‘ORS is effective against diarrhoea mortality in home, community and facility settings; however, there is insufficient evidence to estimate the effectiveness of RHFs against diarrhoea mortality’.

But let’s give the last word to our customers in rural Zambia: They tell us that they don’t always have sugar and salt at home. They do know about SSS, but they often have trouble remembering how to make it correctly. Kit Yamoyo gives them confidence; it helps them to measure the right amount of water and ORS easily. Their children like the colour of the Kit Yamoyo solution and they will drink it, even when sick. Above all, they tell us that the medicine is ‘strong’ (they mean effective) and that it saved their child’s life. So, perhaps K5 ($1) is a small price to pay after all.

Child watching Kit Yamoyo ORS being mixed Child drinking ORS from Kit Yamoyo
A child watches as Kit Yamoyo ORS is mixed | A child drinks Kit Yamoyo ORS from the Kit Yamoyo container

[1] ‘Water with Sugar and Salt’, The Lancet, vol. 312, no. 8084, 1978, pp. 300-301; rehydration.org, ‘Why is Rehydration so Important and How it Works to Save Children’s Lives’, rehydrate.org/rehydration

[2] The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality, Melinda K. Munos, Christa L Fischer Walker and Robert E Black at Johns Hopkins Bloomsberg School of Public Health

 

Comments

  1. Yes, salt, sugar and water are ‘simple’ elements, but as Jane mentions, the practice is not always ‘simple.’ In Nigeria we found that poor people often do not keep much sugar at home; they may not have standard measuring devices (different size spoons and bottles). Also there was the belief that sugar can cause the diarrhea to deteriorate into dysentery. No one said it tasted nasty, which in fact it doesn’t taste like much. ORS packets still require having a standard measure of water, but they ensure that all the ingredients are available in an acceptable package. Jane is right that continued fluids and feeding are an essential component of diarrhea control.

  2. Via email says:

    Hi Simon

    Very interesting article. The one thing that really comes across is; since “the greatest discovery in the 60’s” the same problems still exist, diarrhoea and child mortality. Yes, it’s right to sell ORS. As long as it gets the treatment out to where it’s needed, faster and in a manner that will be used, it’s right!

    To those who challenge whether it is right or wrong, I simply say “after all the years, all the money and all the education, why does the problem still exist?”. Until you [the challengers etc.] come up with answers to that question, it is definitely RIGHT!

    B

  3. Via Facebook says:

    I am ambivalent about these arguments.

    First of all, I think it is wrong and a bit patronizing to assume that an illiterate or semi-literate mother can’t be taught to make SSS at home. God knows much of the IYCF messaging which is seen as such an important promotion platform is much more complex.

    Secondly, while I don’t doubt that the mixture offered in the kits is clinically more effective than plain sugar and salt solution, I wouldn’t want to see mothers getting into a kind of ‘kit or nothing’ mindset in which, lacking access to the kits, and steered away from SSS by the kit marketing, they ended up not treating the child at all.

    Finally, if mothers are saying they don’t have sugar and salt at home, why should we expect that they’d have the kits? I’ll just add that I think ColaLife is a really innovative and interesting project, but I think these questions require more robust and intellectually grounded responses.

    T

  4. Via Facebook says:

    With you, T, especially from the land where ORS/SSS was invented (Bangladesh). BRAC systematically taught generations of mothers how to make SSS in the days before ORS was marketed and their work formed the basis for scaling this up. Now, ORS is available in the market, and is bought here and used by pretty much everyone too, but SSS works as well as ORS!

  5. While we might want to give up on this generation of some mothers in some places finding SSS too complicated lets invest in very good health education of the children who can (easily) learn about the SSS recipe at primary school and over and over again if possible – in science, maths, language classes etc. Its about putting power into their hands and giving them something to try. I think of ORS as the second step once household interventions have not worked (and chidlren can also be taught to recognise the signs here too). Its also important for people to think clearly about what gave their children diarrhoea in the first place and what exists to help them take control of that eg SODIS. If we keep the focus on medicalising and curing then these simple preventable, treatable issues will linger on for decades longer than they need too.

    • Jane Berry says:

      Hi Clare – Good point on school children; in our second ‘wave’ of promotion, our local fieldstaff are talking to schools and teachers. We really wanted to include ‘SODIS’ in this trial – in fact the Kit Yamoyo packaging would support that, but the concerted view was, there were too many variables/innovations already – and SODIS is not yet adopted b y the Zambian Ministry of Health. (We do promote the use of safe water though).

      Finally, one thing that SSS does not do is provide the underlying micro-nutrients that are often lacking and mean that the child cannot fight off the diarrhoea in the first place. Which is where the combined ORS/Zinc Kit recommended by WHO/UNICEF comes in.

      There is some interesting recent research in the latest Lancet series (June 06) on this: eg ‘Preventive zinc supplementation in populations at risk of zinc deficiency reduces the risk of morbidity from child hood diarrhoea and acute lower respiratory infections and might increase linear growth and weight gain in infants and young children. A review by Yakoob and colleagues assessed 18 studies from developing countries and showed that preventive zinc supplementation reduced the incidence of diarrhoea by 13% and pneumonia by 19%, with a non-significant 9% reduction in all-cause mortality’. From what we are finding in the field, and what mothers and Health Centre staff tell us, the effect of Zinc supplementation WITH ORS in the same Kit is indeed promising.

  6. I have not come across anyone saying that mothers cannot or should not be taught to make SSS at home.

    For the record – ColaLife works closely with rural health facilities; most/all have an ORS Corner and they teach how to make SSS. The 4 publications mentioned in the blog post give some very well grounded responses – both for and against ORS/SSS.

    The science tells us, however, that Low Osmolarity ORS combined with Zinc is clinically superior to home-made SSS. But mothers should know about all options to rehydrate a sick child – and breast feeding as number one.

  7. Via Facebook says:

    Response from T (above):
    I was simply referring to this statement from the ColaLife post: “Assumptions about what is right or easy or appropriate for an illiterate mother or carer can’t be taken for granted. Is the SSS recipe really ‘simple’ for her?”.

    Perhaps I have misunderstood it, but the implication here does rather seem to be that does seem to be that making SSS might be beyond an illiterate mother/carer’s capacity.

    Anyway, glad to hear that your approach is complementing existing ones.

  8. That paragraph is meant to pose, as a series of 4 rhetorical questions, the assumptions that are sometimes put to us, ie:

    i) Is making SSS really simple?

    ii) Are sugar and salt always available in a rural home?

    iii) Is it easy to feed homemade SSS to a child? and

    iv) Does SSS do the same job?

  9. Via Email says:

    It was good to read this latest blog. I am glad you posted it as my sister-in-law had also put that argument to us when we were in the UK in April and I had been thinking about it. I came to the same conclusion – that remembering the right proportions and mxing ORS yourself is not that easy and the mother’s confidence that she is doing the right thing is an important factor in persisting with the treatment.

    So although it is kind of sad to commodify and medicalise SSS the balance of the argument is in favour of ColaLife’s approach.

    Tell Rohit to work on a layman’s way of saying ‘adverse risk of hypertonicity on net fluid absorption’.

    J

  10. Annabelle says:

    What a waste of time and money in making such expensive kits and sending them to Africa when local people there could be making their own sugar and salt solution. If the availability of sugar is a problem, then why don’t they mix salt into the cola drinks. After all, cola drinks have known to cause diabetes and obesity. Why do the rich countries automatically assume that the local Africans don’t have the brains and skills to learn common sense skills. Actually, the Africans can teach Canadians how to live in hardship conditions. If you want to help them, then teach them the skills or put up a unit where locals make their own ORS. ColaLife has a hidden agenda of getting all the awards and glory under the pretense of “saving the poor.” Your website posts prove that with all that noise and thumbs ups!

    Annabelle

    • Dear Annabelle, thanks for your comments.

      Some points of clarification:
      – The kits are not ‘sent to’ Africa, but (almost entirely) manufactured and packed in Zambia, by a Zambian company, creating Zambian jobs. A full transfer into local organisations has always been part of the plan – and will be the ultimate success of this project.
      – Kits are sold by Zambian shop keepers to their customers, improving incomes, health and livelihoods. Some of these are earning around $30 a month (in additional gross profit) from selling Kit Yamoyo.
      – The project was co-designed by Zambian stakeholders and partners, with, as you rightly point out, far more ‘brains and common sense’ than we could provide – particularly on what is suitable in their own culture and situation. These include the Ministry of Health, which oversees the project. The private sector approach was the preference of these local partners.
      – The Kit was designed in consultation with people in rural areas, in focus groups run by a Zambian NGO, to meet their needs and preferences. Their needs and responses continue to inform future plans.
      – The project works closely with local clinics, who do teach home-made ORS. However, it is a scientific fact that this does not do the same job as Low Osmolarity ORS and Zinc – it can however save a life if made correctly. Unfortunately, even after many years, it often isn’t.

      Regarding your post below, overuse and misuse of anti-biotics for simple diarrhoea is one of the big concerns of the global health community. However, all of this project’s promoters and retailers are trained in the danger signs indicating a more complex condition and are taught to refer the customer to a health facility (still taking ORS on the journey, as this can sometimes be 20 km or more).

      If you are interested in this area, then as well as the various publications mentioned in the blog post, The Lancet has just published a series on malnutrition and diarrhoea. And I recommend the late great CK Prahalad – on giving the vast majority of the world’s consumers ‘ the dignity of attention and choice’.

      Jane

      PS Sorry about the awards – mostly, we have been nominated, entered by a partner, or invited to enter. Winning has been a huge honour and an even bigger surprise.

  11. Via Google+ says:

    It is right to sell because of the right measurements. The one which is made at home normally on the measurements of sugar and salt is entirely guess work.

    Charlotte
    COTZ Project Officer
    Kalomo

  12. A good debate Jane and raises several good points and especially the difference between social marketing (marketing a message or behaviour change) and using markets to achieve desired change.

    One important factor about using the private sector to distribute these kits is that for every person who is making a small bit of cash out of their sale there is somebody promoting their use and uptake.

    BTW – Annabelle (above) – I suggest that you do a bit more research on Col Life before you make the sort of statement that you do online regarding the organisations.

    PS – Why use condoms when I am told that bits of sheep intestine, if available and used properly can do the same job?

  13. Annabelle says:

    Why was the question asked about “poor people making their own ORS when they could be making their own” when you already have your self-assured opinions.
    Poor argument just trying to win a point. Don’t just assume that ORS is THE cure to diarrhea when patients could be needing antibiotics to fight an infection or medicines to get rid of the worms in their intestines. Sugar and salt solution is needed to prevent dehydration, but no one talks about medicines to cure stomach and intestinal infections.

    BTW – Duncan (above) – Why spend extra bucks to buy a large, thin screen TV when the old fashioned one did the same job!

  14. This debate is not new, and perhaps its a good sign that it is still taking place.

    Here’s a relevant excerpt from a recent publication (2013) by Bhutta et al. in the Lancet (Bhutta Z, Black RE, Chopra M, et al. Authors’ reply. Correspondence. Lancet 2013;382:308.):

    “Although evidence from clinical studies shows that sugar and salt solutions when prepared in the hospital pharmacy work for hydration, translation of this intervention to community application has been a failure (2). Most sugar-salt programmes have been abandoned because of variability in ingredients quality and concentrations, and risks of electrolyte abnormalities in children with severe diarrhoea (3). Furthermore, the broadening of recommended home fluids—from semi-quantified mixtures of sugar and salt to soups, juices, and even plain water—led to the reporting of almost universal diarrhoea treatment coverage, whereas children continued to die of dehydration.

    We focused on interventions that have a clear effect on mortality, and standard oral rehydration solutions have clear benefits in contrast to other alternatives including recommended home fluids. Despite challenges with supplies, substantial progress has been made in coverage of oral rehydration solution (ORS). Recent analysis of ORS use from relevant population-based national surveys shows a slow but steady increase overall. Not only Bangladesh, but also Thailand and Mexico have been able to scale up appropriate use of ORS for childhood diarrhoea and to reduce the proportion of diarrhoea deaths in children (4). Wilson and colleagues (5) noted that one of the clearest differentiators between countries that have successfully scaled up ORS and those that have not was the choice to promote a clear, unambiguous message about the treatment of choice.

    That many children still have more than three episodes of diarrhoea per year stresses that they need to receive treatments of proven effectiveness instead of haphazardly prepared home solutions.”

    • Thanks for bringing more science into this discussion Rohit. Would the authors consider wrongly mixed litre sachets of ORS as “haphazardly prepared home solutions”? Can you enquire?