What’s a Trim Tab? And have we found one to address the childhood diarrhoea death toll?

GRZ ORS and Zinc co-pack

In 1972, Buckminster Fuller, the famous inventor, architect and philosopher, explained his insight about part of a ship – the ‘trim tab’ – and the power of a trim tab as a metaphor, to understand how one small adjustment can bring about transformative change. And I wondered: could co-packaging for ORS and Zinc be the trim tab we need to address the terrible death toll from childhood diarrhoea?

Buckminster Fuller was talking about the power of one person to change society:

“Something hit me very hard once, thinking about what one little man could do. Think of the Queen Mary — the whole ship goes by and then comes the rudder. And there’s a tiny thing at the edge of the rudder called a trim tab. It’s a miniature rudder. Just moving the little trim tab builds a low pressure that pulls the rudder around. Takes almost no effort at all. So I said that the little individual can be a trim tab. Society thinks it’s going right by you, that it’s left you altogether. But if you’re doing dynamic things mentally, the fact is that you can just put your foot out like that and the whole big ship of state is going to go. So I said, call me Trim Tab.”

So, how about applying this metaphor to a small idea that could turn around the behemoth that is children dying from diarrhoea?

I would like to suggest that the co-packaging of ORS and Zinc can be the trim tab against the childhood diarrhoea death toll and this is why.

Throughout my lifetime, this terrible behemoth, children dying from diarrhoea, has trundled on like a massive ocean tanker. Huge efforts have been made to stop it, or change its seemingly inevitable course – perhaps the most significant being the invention of Oral Rehydration Salts (ORS) in Bangladesh in 1964, then the rotavirus vaccine developed in India and approved for use in the USA in 2006. But still the tanker ploughs on. Today around 500,000 children die each year from diarrhoea. That’s one a minute. Diarrhoea remains the second biggest infectious killer of young children. There is nothing new on the horizon that is going to radically change this desperate and unacceptable situation. But several of us think we may have missed something. A simple idea that could have a ‘trim tab effect’ and steer the tanker of diarrhoea death off course. We are gathering under the name of the ORS/Zinc Co-pack Alliance (ORSZCA), and we believe that assembling data and evidence, and talking about co-packaging of ORS and Zinc at every opportunity, to anyone who will listen, will have a trim tab effect.

The recommended, and highly effective, treatment for diarrhoea is ORS and Zinc and it’s been in place since 2004. This recommendation has been thrown at the diarrhoea tanker, in a rather haphazard fashion, for 17 years. Despite these efforts, today, still only 15% of cases are treated with both ORS and Zinc. In the last 17 years we have proved to ourselves that while ORS and Zinc are procured separately, supplied and delivered separately, they are very rarely dispensed and used together, by desperate parents, carers and health workers trying to prevent the death of a child. The co-packaging of ORS and Zinc would change this (obviously).

In Mongu District in Zambia there are 30 rural health centres. October is the peak month for diarrhoea in children. In 2016 and 2017 we carried out research there.  Only 7 of the 30 centres had both ORS and Zinc in stock in October in both years. So, in 23 of the 30 centres there was no way children were able to receive the recommended treatment. In 2016, in these 7 centres 45% of children did. By 2017, when the Ministry of Health had adopted our work and co-pack designs, these centres also had a newly introduced ORS/Zinc co-pack. In October that year, 87% of diarrhoea cases received ORS and Zinc and 90% received them both as a co-pack. That is a huge step change, from one very small trim tab effect: put ORS and Zinc in the same package for dispensing.

In 2010 Fischer Walker and Black undertook a literature review and estimated that Zinc reduces diarrhoea mortality by 23%. 23% of 500,000 is 115,000 lives saved every year.

Co-packaging makes sense from a practical and clinical point of view but if you add in the novelty and excitement – and hopefully affordability – that comes with a well designed co-pack, you have the ‘trim tab’ that could turn around that behemoth, ploughing through the lives of half a million children and their families every year.

Please join ORSZCA and start talking and follow ORSZCA on Twitter @ORSZCA. We need everyone to join this conversation.

Silent video demonstrating the prototype co-pack developed in 2015 for the Zambian Government. By the end of 2020 1.2 million of these co-packs were distributed. In 2019 the DHS survey estimated that 35% of cases nationwide received both ORS and Zinc up from an estimated 1% in 2012.

Mother and child with GRZ ORS/Zinc co-pack