The Global Scene in Diarrheaor

Why Miracles get Rejected

Jon E. Rohde MDFormer Unicef Representative India

Child Survival Revolution• 1982 – James P. Grant Executive Director of Unicef

envisioned a Green Revolution for Children – the Child Survival Revolution

• GOBI embodied the idea that we could reach 100% of children with life saving interventions– Growth promotion– ORS– Breast Feeding– Immunisation

• India has gone far beyond in its health services– but is GOBI universal yet?

Diarrhea Globally and India

• Diarrhea accounts for 12-15% of < 5 deaths globally

• Number one cause in 1990’s, now # 2 thanks to ORS use

• Cases using ORS 33% global - India 26%• India 18 lac deaths <5 years: 2.1 lac deaths

from diarrhea• Contributes up to ½ of all malnutrition which

contributes 35% of all child deaths

Exclusive Breast Feeding offers the Greatest reduction in infant deaths

• Exclusive BF has been shown to reduce infant deaths by 80% compared to non breast fed and 50% compared to mixed fed.

• Diarrhea mortality 10-15 times higher in non-Breast fed compared to Exclusively BF (C.Victora, Lancet)

• Exclusive BF in India is about 25-30% at 4 months and 10-15% by 6 months – 46% 0-6 mos

Why can’t we do the easy things?Why then is Exclusive Breast feeding not

Universal until 6 months?• Infant formula still widely promoted and

used in spite of Code – WHY is this allowed?• Little encouragement by medical profession

and BFHI Hospitals no longer promoting BF – WHY?• 72% deliver in hospital but only 40% start BF

in an hour– WHY?

Exclusive Breast Feeding in India• De-license any facility where BF not initiated within

one hour of delivery• Require all hospitals to be certified BFHI and respect

the Code of Marketing• Teach breast milk importance in schools• > 20 lac ASHA and AWWs and 20 lac newborns per

month - each one can counsel one new mother each month and follow for 6 months – incentive pay – would give greatest U5MR impact of any act

The Miracle of the 20th Century

• “ The discovery that sodium transport and glucose transport are coupled in the small intestine so that glucose accelerates the absorption of solute and water was potentially the most important medical advance of this century”

–Editor the Lancet 1978 (ii 300)

An Ancient Truth

• Sushruta, an ancient Indian medical scholar and the father of Ayurveda (1500 BC) prescribed that cholera victims are to be: ‘given to drink a profuse quantity of tepid water in which rock salt and molasses have been dissolved; or clarified water combined with rice gruel”. (Sushruta Swamhita III, verse II)

Why can’t we do the easy things?

• Why then, is ORS, “potentially the most important medical advance of the 20th century” still used in only one third of cases of diarrhea throughout India?

Breast Feeding Prom

Rota vaccine ORS Rx Pneumonia0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

201420152016

Lives Saved by 2016 with 50% increase in each intervention (LiST projection)

ORS acceptance and UseWhat changes behaviour?

Pediatricians support – – IPA 1982 Urged universal use of ORS by pediatricians – IAP full endorsement for past 20 years – WHY do they

not prescribe ORS?– Lower osmol demand rejected by WHO so in

many countries led to non support by pediatricians – now WHO promotes low Osmol ORS

– Antibiotics are REAL medicines – demanded by clients so doctors accede

–Money!!!! No profit in ORS

What changes behaviour?–Packet size – Egypt, Indonesia one glass packet

popular, convenient, logical• OTC – sell in pan shops – opposed by big pharma• WHO opposition to both 200 cc and 750 cc packet• Now one-glass packet in India - OTC

–Social marketing – huge efforts in India, Pakistan, Indonesia (PATH)• one glass packet reached farthest (liter packed used

by the spoon-full in any case)• “If your Doctor doesn’t prescribe ORS….better

change Doctor!”

What changes behaviour?

–SSS vs ORS packets – WHO vs Unicef – –Why not BOTH? - Controversy killed it: “if WHO

and Unicef cant agree, who are we to decide?”

–Diarrhea definition – 3 liquid stools? Why?– Then how to start before dehydration begins? –Why wait for 3 stools?? Start early, at first sign of

diarrhea and replace losses as they occur!

What changes behaviour?

–It’s in the name! “R” for Rehydration vs Replacement –“I don’t see dehydrated kids so I don’t

need to give ORS”– determines when you start giving ORS at

onset, or only if child is dehydrated?

Oral Replacement Solution replace losses from first sign of diarrhea

Client Expectations – Market Strategy• Stop the Diarrhea• Restore energy• Combat fussiness• Improve appetite• Need a real medicine• ORS too cheap to be of value• Its not even patented – real pharmas don’t even make it• Its Only what they give you in Gov’t Clinic!

• Our Message:

Save the child’s life !(not credible)

Rural Providers in India• Over 3 million – all live in rural areas with no MBBS• 10 times as many as MBBS doctors -• First choice of 85% of rural health seeking• Responsive, affordable and culturally accepted• World Health Partners (WHP) in Bihar training and

franchising some 14,000 RHPs in SKY Care/Sky HC• Other NGOs work with RMPs

Why ignore them?

Rural Providers in India• Recent survey of clients consulting Sky providers:– 85% of diarrhea cases (n=481) used ORS vs NFHS

-26-33%– 81% respiratory cases (n=850) received antibiotic (most

injection rather than oral) vs NHFS 13% given antibiotic• Huge ‘Missed Opportunity” RHPs, ASHAs, Med

shops – the Reality of Medical Care in Rural India

BRAC and BangladeshOnly combined approach of SSS-ORS at national scale• Change of culture – BRAC taught every H/H to

make labon-gur solution at first sign of diarrhea – now drinking is part of the culture

• Top user of ORS packets in the world with 77% to 83% use last episode – market place flooded ORS

• Dramatic decline in mortality from diarrhea: – 1972 U5MR of 220 – diarrhea #1, 40% of deaths– today U5MR of 48 – diarrhea #6 – 10% of deaths;

India can perform Miracles

• Polio elimination deemed ‘impossible’ only 10 years ago – yet it has been eliminated!

• Incredible mobilisation of workers, volunteers and communities – lacs of people involved

• Polio vaccine reached 99% of <5s over and over again – many kids received 20 doses or more

• Why not ORS for all diarrhea cases? • Why not exclusive BF for all newborns to 5-6

months old?

What About Urban Slums?

• Urban poor have more diarrhea – more “modern medicine” - ?less ORS

• Urban poor more exposed to “modern” media and less likely to breast feed

• Does NRHM reach into the slums? ASHAs?• Can TV and other marketing reach slum

population to promote ORS, Breast Feeding?

What If India Did?• Increase Exclusive BF, ORS use, Pneumonia Rx,

by 50% over current levels by 2016 ?• 2.5 lac <5 years saved per year – U5MR drop

from current 59 to 49/1000• MDG for India U5MR is 41

BF Promotion Rx Pneumonia ORS Total lives Saved0

50,000

100,000

150,000

200,000

250,000

300,000

2.5 lac fewer deaths in 2016U5MR 49

U5MR MDG of 41?It CAN be Done!

Focus on the MiraclesAnd

Make them Happen