Syed Saad Ahmed – It Is the Greatest Medical Advancement of the 20th Century and Has Saved Millions of Lives. Why Are We Not Using It?


Fellowship 2024

Syed Saad Ahmed

Syed Saad Ahmed


It Is the Greatest Medical Advancement of the 20th Century and Has Saved Millions of Lives. Why Are We Not Using It?

Saad Blog 1 - Image 1 - Featured Image

Introduction

Salt, sugar and water. That’s all it could take to save a life. This combination, known as Oral Rehydration Solution (ORS)*, has been hailed by The Lancet as the most important medical advance of the 20th century.1 Between 1982 and 2007, it averted roughly 50 million deaths due to diarrhea among children younger than five.2 While ORS does not cure or stop diarrhea, it replenishes lost fluids and salts, thereby preventing life-threatening dehydration.3

The treatment’s history is equally fascinating. While it had been used since the 1940s,4 Dr Dilip Mahalanabis was the first to deploy it at a large scale in field settings.5 During the Bangladesh war of 1971, 6,000 people were arriving in refugee camps every day, leading to overcrowding and cholera.2 Without adequate intravenous saline solution or staff to administer it, Dr Mahalanabis and his team handed out ORS. The results were instantaneous and remarkable: mortality dropped from 30% to 1% in eight weeks.

Despite ORS being lauded as a “magic bullet,”6 less than half of children with diarrhea received the treatment in 2022.7 By augmenting its use, we could potentially save an additional half a million lives a year.8

Reasons for Low Uptake

Alt Text: The poster has a pink background. On the top is a bowl of salt, a bowl of sugar, and a glass of water. Below is a child hugging a water drop. It depicts that a combination of salt, sugar and water leads to a healthy child in cases of diarrhea.

A systematic review of studies from 23 countries between 1981 and 2020 has analyzed the barriers and facilitators to ORS use.9 Availability, accessibility, and awareness have been major barriers, but over time, many countries have made great strides in these respects.10 But even where ORS access and awareness are not challenges, ORS use can remain subpar. A recent Science study found that it remains underprescribed.11 The reason? Despite being aware of its life-saving potential, healthcare providers assumed that people did not want ORS. This assumption is unfounded because in the household surveys the study authors conducted, people reported it as their most preferred treatment.

Even among patients who showed a picture of ORS on their phones and said they had received a prescription for it earlier,12 doctors prescribed the treatment only 55% of the time.11 Among those who did not state a preference, 28% received the treatment.

Considering that Indian doctors sometimes prescribe expensive medicines, often at the behest of pharmaceutical companies,12 the study’s authors examined the role of financial incentives in the underprescription of ORS. They also hypothesized that stock-outs could play a role. However, based on their results and the prevalence of these barriers, they estimated that financial incentives and stock-outs explain only 5% and 6% of underprescribing respectively, while provider misperceptions account for 42%.

The study’s authors identified the following reasons for the healthcare providers’ assumptions regarding ORS:13

  1. Since the salts don’t cure diarrhea, healthcare providers thought their patients wanted something more.
  2. Providers might think that patients would get ORS elsewhere.

I imagine these misperceptions would only be compounded by the larger issues surrounding doctor-patient relationships. In India, for instance, one in four people face discrimination while accessing health services due to their caste and religion.14 Underprivileged and low-income patients often face neglect and dehumanization.15

The Science study was conducted in the Indian states of Bihar and Karnataka, which are diametrically opposed. Bihar is one of India’s poorest states16 and lags on economic and social indicators, while Karnataka, about 1,000 miles away, has a higher per capita income, education levels, and ORS use. However, the findings would probably hold true in many parts of India and the world, for reasons I shall discuss below.

The Scourge of Simplicity

One could say that ORS is a victim of its simplicity. This has been true of the treatment since its inception (see image below), an aspect that is often overlooked in conversations around its use.

Alt text: The image contains the following quote by Joshua Nalibow Ruxin: “The history of ORT reveals an extraordinarily long path to discovery followed by an ongoing struggle for legitimacy and implementation. When examined in historical context, the account lends itself to discussion of many of the themes which perplex medical historians: the conflicts between "high" and "low" technology, between laboratory and clinical science, and between public health and medical research. Furthermore, it demonstrates how the prejudices of the medical establishment and its reverence for advanced technology can postpone life-saving discoveries.” On the left is an AI-generated watercolour image with tents and silhouettes of people.

 

In some ways, ORS reminds me of the public health intervention of washing hands before surgeries to prevent infections. In 1846, Hungarian doctor Ignaz Semmelweis found that doctors were transmitting infections to women in maternity wards by examining them after doing autopsies and washing hands could prevent this.17 However, medical professionals derided him and his findings. While others echoed his claims, most notably Florence Nightingale,18 handwashing to prevent infections became common only decades later.

In certain contexts, underwhelming perceptions of ORS have filtered down to patients, who might prefer other treatments over it.19

The scholar Rachel Hill-Clifford talks about how larger health equity and access issues can affect certain treatments. Citing the limited accessibility of healthcare in Guatemala, she writes: “If families do pay and take the time to travel to a healthcare facility, they want to be compensated for their efforts with a treatment perceived as strong and effective. ORT is not perceived as such a treatment”.20

The Way Forward

In public health interventions, we need to embrace and evangelize the idea that in certain cases, less is more.21 Healthcare providers overprescribe certain treatments, such as antibiotics,22 where simpler ones would suffice.

But merely providing a simple solution or sharing knowledge regarding it is not enough. We also need to address deep-rooted motivations and beliefs. These might seem irrational, but often have a logic to them.

However, there is no one-size-fits-all solution.24 What may have worked in one location might be unsuitable for another. When implementing strategies to increase ORS use — or for that matter, any public health intervention — it is important to consider the local context and social determinants of health.23

In certain contexts, the solution could be deceptively simple. The Science study’s authors mention that since patients nudging doctors increased ORS prescriptions, just putting up a poster telling patients to ask for ORS rather than, say, antibiotics could be a way forward. Providers too thought it would give them more credibility when they prescribe “something as simple and basic as a pack of salts”.13

Occam and his razor26 would agree — sometimes, the simplest solution can be the best one. The first step would be to acknowledge it.

Notes

*ORT (Oral Rehydration Therapy) refers to the proper use of ORS, but both terms are often used interchangeably. 

Disclaimer

Some of the visuals used in this blog are AI-generated on Canva.

Citations

  1. Water with Sugar and Salt. Lancet. 1978;312(8084):300-301. doi:10.1016/s0140-6736(78)91698-7
  2. Fontaine O, Garner P, Bhan MK. Oral rehydration therapy: the simple solution for saving lives. BMJ. 2007;334:s14. doi:10.1136/bmj.39044.725949.94
  3. Rehydration Project. Frequently Asked Questions. Accessed May 25, 2024. https://rehydrate.org/faq/all-questions.htm.
  4. da Cunha Ferreira RM, Cash RA. History of the development of oral rehydration therapy. Clin Ther. 1990;12 Suppl A:2-13.
  5. Mahalanabis D, Choudhuri AB, Bagchi NG, Bhattacharya AK, Simpson TW. Oral fluid therapy of cholera among Bangladesh refugees. Johns Hopkins Med J. 1973;132(4):197-205.
  6. Ruxin JN. Magic bullet: the history of oral rehydration therapy. Medical History. 1994;38(4):363-397. doi:10.1017/S0025727300036905
  7. Diarrhoea remains a leading killer of young children, despite the availability of a simple treatment solution. UNICEF. Published January 12, 2024. Accessed 17 May 2024. https://data.unicef.org/topic/child-health/diarrhoeal-disease/
  8. Santosham M, Duggan CP, Glass R. Elimination of diarrheal mortality in children – the last half million. J Glob Health. 2019;9(2):020102. doi:10.7189/jogh.09.020102
  9. Ezezika O, Ragunathan A, El-Bakri Y, Barrett K. Barriers and facilitators to implementation of oral rehydration therapy in low- and middle-income countries: A systematic review. PLoS One. 2021;16(4):e0249638. Published 2021 Apr 22. doi:10.1371/journal.pone.0249638
  10. Wilson SE, Morris SS, Gilbert SS, et al. Scaling up access to oral rehydration solution for diarrhea: Learning from historical experience in low- and high-performing countries. J Glob Health. 2013;3(1):010404. doi:10.7189/jogh.03.010404
  11. Wagner Z, Mohanan M, Zutshi R, Mukherji A, Sood N. What drives poor quality of care for child diarrhea? Experimental evidence from India. Science. 2024;383(6683). doi:10.1126/science.adj9986
  12. Thiagarajan K. There’s a cheap and effective way to treat childhood diarrhea. So why is it underused? NPR. Published February 27, 2024. Accessed June 18, 2024. https://www.npr.org/sections/goatsandsoda/2024/02/27/1233134770/childhood-diarrhea-effective-treatment-oral-rehydration-salts.
  13. Gadre A, Shukla A. How Pharmaceutical Companies Entice Doctors into Prescribing Expensive Medication. The Caravan. Published April 16, 2016. https://caravanmagazine.in/vantage/pharmaceutical-companies-entice-doctors-prescribing-expensive-medication
  14. An affordable diarrhea treatment could save thousands of children’s lives. RAND. Published May 15, 2024. Accessed May 25, 2024. https://www.rand.org/pubs/articles/2024/an-affordable-diarrhea-treatment-could-save-thousands-of-children.html.
  15. 30% Muslims, 20% Dalits and Adivasis report discrimination in accessing healthcare: Oxfam. The Wire. Published November 23, 2021. Accessed June 24, 2024. https://thewire.in/health/one-in-4-indians-face-discrimination-while-accessing-healthcare-due-to-caste-religion-oxfam
  16. Kumbhar K. Distrust of Indian doctors isn’t new. Class-caste bias always ruled medical profession. The Print. Published August 19, 2022. Accessed June 24, 2024. https://theprint.in/opinion/distrust-of-indian-doctors-isnt-new-class-caste-bias-always-ruled-medical-profession/1089185/
  17. Bihar, Jharkhand, UP among poorest states: Niti Aayog’s poverty index report. The Times of India. Published November 26, 2021. Accessed June 23, 2024. https://timesofindia.indiatimes.com/india/bihar-jharkhand-up-among-poorest-states-niti-aayogs-poverty-index-report/articleshow/87937717.cms.
  18. Poczai P, Karvalics LZ. The little-known history of cleanliness and the forgotten pioneers of handwashing. Front Public Health. 2022;10:979464. Published 2022, Oct 20. doi:10.3389/fpubh.2022.979464
  19. Hillier MD. Using effective hand hygiene practice to prevent and control infection. Nurs Stand. 2020;35(5):45-50. doi:10.7748/ns.2020.e11552
  20. Wilson SE, Morris SS, Gilbert SS. ORS Case Study: India. Published November 2012. Accessed May 26, 2024. https://shopsplusproject.org/sites/default/files/resources/India_ORS%20Case%20Study.pdf.
  21. Hall-Clifford Rachel. Underbelly. 2024. doi:10.7551/mitpress/15135.001.0001
  22. Masi C. When less is more in public health. Perspect Biol Med. 2008;51(3):479-483. doi:10.1353/pbm.0.0037
  23. Sulis G, Daniels B, Kwan A, et al. Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya. BMJ Glob Health. 2020;5(9):e003393. doi:10.1136/bmjgh-2020-003393
  24. Rämgård M, Ramji R, Kottorp A, Forss KS. ‘No one size fits all’ – community trust-building as a strategy to reduce COVID-19-related health disparities. BMC Public Health. 2023;23(1). doi:10.1186/s12889-022-14936-6
  25. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2(Suppl 2):19-31. doi:10.1177/00333549141291S206
  26. Duignan B. Occam’s razor | Origin, Examples, & Facts. Encyclopedia Britannica. Accessed June 14, 2024. https://www.britannica.com/topic/Occams-razor.

Stay in Touch with Syed Saad Ahmed


Linkedin

ABOUT THE THOUGHT LEADERSHIP FOR
PUBLIC HEALTH FELLOWSHIP

The mission of the Boston Congress of Public Health Thought Leadership for Public Health Fellowship (BCPH Fellowship) seeks to: 

It is guided by an overall vision to provide a platform, training, and support network for the next generation of public health thought leaders and public scholars to explore and grow their voice.


RETURN TO THE THOUGHT LEADERS






Tagged , , , , , , , , , , , ,