[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.” 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.
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, 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.
 ‘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
 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