Diarrhoea and malnutrition - ORT and mortality    
Book review : "Questioning the solution" Claudio Schuftan 02.03.98
Questioning the Solution David Brewster 02.03.98
ORT and mortality Andre Briend 02.03.98
no title David Werner 01.04.98
Diarrhoea nutrition and mortality Andre Briend 04.05.98
diarrhoea and malnutrition Andre Briend 05.05.98
Re: diarrhoea and malnutrition Abdullah Dustgheer 05.05.98
Message from David Werner David Werner 31.05.98

From: avivaatnetnam.org.vn

Date: Sat, 28 Feb 1998 11:55:44 -0700

Subject: book review



The Politics of Primary Health Care and Child Survival

with an in-depth Critique of Oral Rehydration Therapy


David Werner and David Sanders

with Jason Weston, Steve Babb and Bill Rodriguez


A Healthwrights Paperback, 1997, 207 pp., Health Wrights, 964 Hamilton Ave, Palo Alto, CA 94301, USA, $30 airmail overseas postage paid.


Here is a new book whose time had come; a book that succeeds in painting the big picture of the the health situation in the 1990s worldwide showing us how often the trees do not let us see the forest. The book is a true wake up call to new realities.

It is a book written in a direct language by a group of authors who are no newcomers to the scene. They set out to write a book for a wide readership of students, health workers, activists, primary health care (PHC) workers, health and devevelopment planners and policy makers and is based on their respective long experience in the field.

The book makes a passionate call for rectifying what the authors see terribly wrong with PHC in the mid nineties. It calls for sterengthening international solidarity, networking and coalition building among the like-minded progressive health practitioners who agree with the book's argumnets. In so doing, it energizes the reader; it makes one question what one is doing and leaves one little chance, but to take a stand. Each of its 21 chapters is full of data carefully woven into a lucid argument that is convincing and compelling from beginning to end. The book's many examples give a human face to otherwise faceless social problems and abuses thus exposing them to the scrutiny of the reader.

In short, we are sternly warned of the current global regressive trend in the health status of the growing number of the poor and are alerted to the so many unfulfilled promises of PHC and the Child Survival Revolution. The failures and successes of the current health and nutrition system to protect the life and health of poor children are chronicled in a way that show how 'magic bullet' technologies ultimately have only brought about some survival, but not without asking the key question: 'survival at what cost?'...

Ultimately, the futility of all safety net approaches used as damage control measures to resolve deep rooted health problems is masterfully brought to the fore.

The rise and fall of PHC with its (too) many stopgap measures lends itself for the authors to drive their main arguments. One of them criticizes the prioritization of product over process and is presented in the form of an in depth critique of oral rehydration therapy (ORT).

It contrasts the use of oral rehydration solution packets with the use of home-based, food-based ORT. The book basically objects to the pharmaceuticalization of this simple solution, a typical example of how PHC has been brought into the flawed Western medical model where doctors still feel unmotivated to promote social change and self-reliance.

All this analysis leads the authors to advocate that what really ultimately determines the health status of poor people are wider social equity issues that can only be addressed by embracing the political dimensions of the problem. Solutions are not about health per-se, we are told, but about triggering organized popular demands for an overall fairer treatment in society. This is made clear through showing us examples of poor people's empowering initiatives from different continents. But they also show us how these initiatives systematically run into obstacles created by the existing national and international power structures. The role of international pharmaceutical houses, the IMF and the World Bank are reviewed in this regard. The latter is seen as excesively intruding into Third World health care policy-making, leaving WHO a weak second. The Bank's 1993 World Development Report on health gets special attention. The authors brand it 'old wine in new bottles', and a report about how to achieve a 'healthier poverty'. The complex concept of disability-adjusted life years (DALYs) introduced in said report is heavily and fittingly criticized as well.

The global roles of WHO and UNICEF are also scrutinized in a special Appendix under the optic of whether they do contribute to a 'real Health For All'. Both agencies are shown to indeed have addressed the real, basic causes of of ill-health in the world , but also of implementing measures that ultimately avoid tackling them; they are further made accountable for the non-sustainability of the measures they promote. WHO and UNICEF are thus written off by the authors as potential decisive leaders in the struggle for (needed) social change.

The authors show anger at the mockery made of the empowering part of PHC having replaced it by a drive for what really is a disempowered compliance by people together with a high dose of blaming the victim. A whole rhetoric has risen to justify some of the ital sins being committed in the name of the Alma Ata Declaration, namely sins related to going from genuine popular participation to compliance, from social to technological interventions, from cooperative approaches to private enterprise, from process to product, from problem-posing learning to pre-charted training, from critical analysis to social marketing, from Health for All to raising survival rates, and ultimately from not shifting from a humanitarian to a political agenda.

Too many actors in PHC still poorly understand the web of underlying causes of human ills leading them to the ill-conceived solutions we keep seeing. ("Trying to combat malnutriton by simply combatting infection, without confronting the underlying socioeconomic problems is like trying to cure diarrhea with kaopectate"). The interventions introduced simply do not simultaneously emphasize actions to address the root causes. Inequity and poverty cannot just be accepted as inalterable facts.

The authors think the prevailing reductionistic attitude towards PHC represents a veritablea betrayal of its liberating componenents --with the real transformative potential of Alma Ata remaining largely on the drawing board. Therefore, they posit, PHC has never really failed; it just has never been tried!

On the economic front, good evidence is given correlating persistent high child mortality rates primarily with income distribution disparities and this leads the authors to assert that the alleviation of poverty is actually a precondition to health improvements.

How the global situation of pauperization is ongoingly and progressively affecting access to health care in the United States makes for additional intersting reading.

Additionally, we are given an insight into how, even in China --where political commitment to equity appears to be slipping-- it is questionable whether the health gains attained will now endure.

In closing, the authors re on key issues. They think the grim current situation threatens to reverse the hard won global progress made during the last 20 years. We are reminded that it is possible for health workers to function within an inequitable social order while still working to transform it. A call is, therefore, made for them to work towards minimizing the inequalities of the existing power structure since this will do more to reduce high infant mortality than all preventive measures put together: social and political commitment to equity is the key determinant of good health at low cost.

The challenge is not only to find and understand the root causes of the problem, but equally to find workable solutions. No road map is offered. But different attempts to find a way are shown in which the social mobilization component of PHC was somehow resurrected.

I could not agree more with the authors in that a need exists to launch a concerted global effort to consolidate popular movements that think globally and act locally. This by creating opportunities for popular pressure to demand the social transformations needed to counter the regressive social trends we are seeing.

At the heart of the conclusions of the book is a call for a Child Quality of Life Revolution in which children will not only survive, but will be healthy in the fullest sense of wellbeing.

Everybody has to take a stand, demanding action and accountability, we are told. We have to stop the 'progressive' rhetoric and get down to meaningful business. We cannot sidestep the political challenge posed by a more comprehensive approach to PHC and must move away from calls for narrow-focused 'cost-effective' interventions that do not challenge the status-quo.

All in all, this is a one-of-a-kind book that reminds us of the ground-breaking role "Food First" by Lappe and Collins played some twenty years ago.

It is not without flaws, though, and some readers will find some chapter conclusions occasionally being oversimplistic, sometimes using sweeping one-liners. Nevertheless, even people politically unsympathetic to the book's political line will find it worth reading. Students will find endless inspiration. A good glossary is included and the book is pleasantly and fittingly illustrated. References and endnotes are generous and there is a recommended further reading list plus some addresses to join groups that are working along the lines advocated by the book.


Claudio Schuftan, MD.

I. P. O. Box 24 - Hanoi, Vietnam, Fax: (84-4) 844-5389

Email: avivaatnetnam.org.vn

From: David.BrewsteratCASRDH.HEALTH.nt.gov.au

Date: Mon, 02 Mar 1998 15:08:03 +0930

Subject: Ngonut: Questioning the Solution


Claudio Schuftans's review of Werner and Sanders' new book cannot go unchallenged. David Sanders kindly gave me a copy of the book on his recent visit to Darwin, so I certainly bear him no malice, but this book is too far from evidence-based medicine for my approval. Many important claims are made with no data to support them. In the end, it is political rhetoric instead of good medicine. This is especially disappointing as a sequel to "Where There is No Doctor", which deserved its good reputation.

The basic argument is for salt-sugar solution (SSS) which can be made up at home instead of ORS in packets, which has been a recurring theme of public health debate, and I am not unsympathetic to that argument. But there have been so few sustainable SSS projects in which families have been shown to remember the formula of the safe solution when children have diarrhoea that this book's argument is unsustainable. ORS has been an important advance for health facilities, so it is a pity this book appears to discredit it without making a convincing case from an evidence perpective. However, it is true that the emphasis on oral rehydration ignored (until recently) the importance of persistent diarrhoea. I would favour home-based programs under circumstances where health facilities were inadequate, but not as a universal program for diarrhoea, and certainly not always instead of ORS in packets

As a paediatrician treating children with diarrhoea, I am too aware of the need for potassium in rehydration solutions and the dangers of incorrect sodium concentrations in home-based solutions. Of course mistakes can be made with packets going into a glass of water instead of a litre, but health facilities need to use the best solution and that means with potassium. Of course, empowering people to manage their children's diarrhoea without the need for health workers is fine, but not in order to deny them optimal treatment which is still accessible to most populations in even very poor countries like Malawi and Zimbabwe (where I have worked).

This book does not provide any evidence that home-based solutions are more accessible as a sustainable and effective intervention than ORS made widely available through all levels of health facilities. Successful home-based SSS projects have needed enormous educational/promotional activities which are excellent, but expensive and difficult to sustain.

I feel that Werner and Sander's arguments would have been better supported on issues such as abuse of medical treatment of diarrhoea (antidiarrhoeals or antibiotics) gastro-oesophageal reflux (e.g Cisapride), behavioural problems (e.g Ritalin), viral infections with antibiotics, etc., but applied to ORS I found it unconvincing without being unsympathetic to the general viewpoint.


David Brewster, Department of Paediatrics

Northern Territory Clinical School, Darwin, Australia

Date: Mon, 2 Mar 1998 10:46:19 +0100 (MET)

From: briendatext.jussieu.fr (Andre' BRIEND)

Subject: Ngonut: ORT and mortality


Dear NGOnuts,

The current debate about David Werner's book prompts me to flag a paper published a few years ago on this issue and which remained almost un-noticed, because the authors made the mistake to publish it in a journal not picked up by Medline. This is not an 'anti ORT' paper, but an attempt to show that ORT is not a magic bullet, and that just pushing this component of PHC will not make miracles. It stresses that diarrhoea kills not only by dehydrating children. In contrast to David's book, (which I haven't read, sorry) this paper relies on what I believe are the best data available on this topic.



Does ORT reduce diarrhoeal mortality?


HEALTH POLICY AND PLANNING; 1992; 7(3): 243~250

International Centre for Diarrhoeal Disease Research (ICDDR), Bangladesh, Institut Franpais de Recherche Scientifique pour le Developpement en Co-operation (ORSTOM), New England Medical Centre, Tufts University School of Medicine, USA

Abstract : Trends in infant and child mortality from all diarrhoea-related causes and from acute watery diarrhoea were examined in a rural community in Bangladesh, during the three years preceding and the 10 years following the introduction of an oral rehydration therapy (ORT) programme. A significant increase in infant mortality due to acute watery diarrhoea was observed throughout the study period. Child mortality due to acute watery diarrhoea did not decrease during this period. The programme ensured universal knowledge of the oral rehydration solution and the availability of glucose-electrolyte sachets in every household. Yet the inadequate formulation of messages concerning the role of oral rehydration may have caused its incorrect use : oral solutions being administered to too few infants, in too small quantities, and for too short periods. The decline in infant mortality from other causes may also explain the increased contribution of diarrhoea as a cause of death through a replacement effect.

The findings suggest that efforts should be continued to ensure appropriate formulation of messages promoting ORT for its correct use. ORT should also be viewed as one component among others in diarrhoeal diseases control programmes if diarrhoea mortality is to be reduced.


Dr. Andre' Briend

INSERM U 290, Hopital Saint Lazare

107 rue du Faubourg Saint Denis, 75 475 Paris Cedex 10, France

tel 33-1-45 23 24 07, tel (direct) 33-1-48 00 56 04, fax 33-1-47 70 28 35

From: David Werner

Date: Wed, 1 Apr 1998 20:33:08 +0100 (BST)

no title


Please share with David Brewster and other NGOnuts.


Dear Dr. Briend,

Thank you for your e-mail of Mar 3, 1998. I am glad you communicated to other NGOnuts about the paper by Flaveau et. al. titled "Does ORT reduce diarrhoeal mortality?" which shows that in the study area child mortality from diarrhea increased in spite of increasing promotion and use of ORT.

Indeed, we quote this reference in "Questioning the Solution" (Part 2 ref.

56). And, as you do, we draw the conclusion that while ORT is important to reducing death from diarrhea, other factors such as adequate nutrition may be equally or more important. We speculate that, at least in the study area, the detrimental effects of growing poverty and cut backs in public services may outweigh the positive effects of ORT.

I wish you had seen our book before you commented to NGOnuts that, "In contrast to David's book (which I have not read, sorry) this paper relies on what I believe are the best data available on this topic." We draw on the same data—and more. The information in our book is extensively researched, and draws not only on hundreds of published papers of reputable journals, but also on the first hand experience of many field workers. The section on ORT, alone, has 245 references, including the one you quote. So please be careful about taking at face value what persons with conflicting views may say. David Brewster accuses us of "political rhetoric." Perhaps this is because his politics, at least regarding, ORT differ from our own. But, contrary to his claim, our conclusions are based on solid research as well as direct field observations.

Although David Sanders gave David Brewster a copy of "Questioning the Solution," it seems Brewster has not read it carefully. We by no means make an unqualified recommendation for home drinks made with sugar and salt (SSS), as Brewster suggests. Indeed, we quote from numerous studies which show that sugar-based solutions (whether ORS or SSS), tend to be less effective and less safe than cereal-based drinks, especially where traditional fermented weaning gruels are present in every household and can be easily adapted for oral rehydration. I had thought that we stated this loudly and clearly—but I guess not clearly enough for those whose minds are pre-set on different viewpoints. (It also took WHO years to finally acknowledge the wealth of evidence in favor of cereal-based ORT.)

Also David Brewster comments on that "Werner's and Sanders' arguments would have been better supported on issues such as abuse of medical treatment of diarrhoea (Antidiarrhoeals or antibiotics) . . . etc." I suggest he look again at the book. A separate section of the book looks closely at precisely these concerns.

I am glad Claudio Shuftan's provocative review has generated a lot of discussion. But I would encourage concerned persons to read the book itself before drawing too firm conclusions about it. Issues such as ORT certainly do have a political component, the consideration of which is inescapable in a serious discussion of the continuing high child death rate from diarrhea.

Thank you for communicating your thoughts. With best wishes, David Werner


HealthWrights, Workgroup for People's Health and Rights

964 Hamilton Avenue, Palo Alto CA 94301, USA

email: healthrightsatigc.apc.org, http://www.healthwrights.org

Date: Thu, 4 Jun 1998 13:27:58 +0200 (METDST)

From: briendatext.jussieu.fr (Andre' BRIEND)

Subject: Diarrhoea nutrition and mortality


Dear David Werner,

Let me reply shortly on NGO nut to your comments :

1- The paper I quoted from Bangladesh (does ORT reduce diarrhoeal mortality ? , Health Policy Planning, 1992; 7: 243-50) showed an increase in diarrhoea mortality despite intense ORT programme (and improvement of nutritional situation). THIS HAPPENDED IN A CONTEXT OF DECLINING OVERALL CHILD MORTALITY. I have no explanation for these findings. In the discussion section of this paper, many explanations are raised. Difficult to say which one is relevant.

2- Despite many claims in the litterature that preventing / treating infections are a good approach to prevent malnutrition, the evidence in favour of this assertion is weak. The litmus test would be to see nutritional status of children improve markedly after implementing these programmes. Such evidence is still lacking. To my knowledge, the largest attempt in this direction is described in the paper quoted below. Programmes to prevent / treat infections do reduce mortality. They should receive highest priority. They should not be considered as an alternative to improving chidlren's diet.

Rousham EK, Gracey M. Persistent growth faltering among aboriginal infants and young children in north-west Australia: a retrospective study from 1969 to 1993. Acta Paediatr 1997;86:46-50.

Abstract: The objective was to examine long-term changes in the growth of Aboriginal infants and young children in the Kimberley region in the far north-west of Australia from 1969 to 1993.A retrospective analysis of anthropometric data (weight and length) routinely collected on 0-5-year-old children in 5-year cohorts from 1969 to 1993 was carried out.From 1974-78 to 1989-93 there has been a significant increase in mean birthweight (ANOVA p < 0.05).The percentage of low birthweight infants (< 2500 g) declined from 14% in 1979-83 to 10% in 1989-93 (p < 0.001).There were no consistent improvements in the growth patterns of infants from birth to 60 months.All cohorts displayed pronounced growth faltering in weight-for-age and height-for-age from 6 to 12 months of age and fell significantly below both the NCHS reference values and mean values for healthy breastfed infants.In conclusion, reductions in Aboriginal infant mortality and infectious disease rates over the past 20 years have not been accompanied by improved growth.The persistence of child malnutrition in these communities may warrant a shift in attention from disease treatment and prevention to a better understanding of nutritional influences, particularly weaning practices, during infancy and early childhood.


Dr. Andre' Briend

INSERM U 290, Hopital Saint Lazare

107 rue du Faubourg Saint Denis, 75 475 Paris Cedex 10, France

tel 33-1-45 23 24 07, tel (direct) 33-1-48 00 56 04, fax 33-1-47 70 28 35

Date: Fri, 5 Jun 1998 12:54:48 +0200 (METDST)

From: briendatext.jussieu.fr (Andre' BRIEND)

Subject: Ngonut: diarrhoea and malnutrition


Dear all,

David Brewster prompts me to react.

David Werner's comments on "lack of food rather than frequent diarrhoea" causing malnutrition may be drawn from one of my papers. I won't go against it.

Some comments:

1- Studies on the relations between diarrhoea and growth show that most episodes have no lasting impact. There seems to be catch up after most episodes; When you look at the nutritional balance, then it is clear that short episodes cannot have a lasting effect (nutritional cost of growth much less than cost of maintenance).

2- There is no doubt that prolonged repeated episodes may induce malnutrition in some children. The problem is that community prevalence of prolonged diarrhoea is usually not enough to explain more than a small part of the overall growth deficit; In other words, virtually all children are growth retarded, but only a small proportion have diarrhoea nearly all the time.

3- It has been argued that most children have chronic inapparent infections that may have an effect on appetite and growth. Fine, why not ? Looks possible. Little evidence so far.

To me this debate has to be put in practical terms. Should we expect AT THE COMMUNITY LEVEL a better growth improvement with antiinfection programmes ?

or by improving the diet ? Difficult to answer. What I observe is that when 1st class preventive / curative medicine is introduced in a third world environment, it does not make a difference in terms of growth. Now, the problems are i) these programmes may have done nothing against very frequent inapparent infections ii) growth improvement was never observed either after implementing a nutritional programme. I argue that none of these programmes could reproduce a first world diet in a third world environment. Most of them limited themselves to distributing high protein low fat food low mineral high fiber supplement (if we could improve the mineral content, I would recommend these supplement to obese people who want to lose weight and lower their blood cholesterol) and were surprised to see no improvement. I don't want to mention growth monitoring only programmes.

Anyway, more research is needed definitely on this topic.



Dr. Andre' Briend

INSERM U 290, Hopital Saint Lazare

107 rue du Faubourg Saint Denis, 75 475 Paris Cedex 10, France

tel 33-1-45 23 24 07, tel (direct) 33-1-48 00 56 04, fax 33-1-47 70 28 35

Date: Fri, 5 Jun 1998 17:06:42 -0400

From: adustagheeratunicef.org (ABDULLAH DUSTAGHEER)

Subject: Re: diarrhoea and malnutrition


Dear all,

Concerning the issue of "food" v/s "infectious diseases" in the

malnutrition equation, is it a question of "either/or" or "both"? The

difficulty is that we have never been able to allocate a weightage to

those two determinants. In the 60's/70's malnutrition was seen as

mainly a "food" problem Then during the 80's/90's "infectious

diseases, mainly diarrhoea" is seen as having a bigger weight in the

causation of malnutrition than "food insufficiency".

12 years ago, while working in Mauritius I conducted nutrition surveys

on the more developped main Island of Mauritius and the lesser

developped dependency Island of Rodrigues. The prevalence of

malnutrition among under-five children was higher and U5's mortality

rate lower on the Island of Mauritius which has a better primary

health care and sanitation system than the Island of Rodrigues at that

time. Does not better health care and sanitation (especially

reduction of malaria and worm infestation + safe water in the case of

Mauritius) dramatically improve survival of children without an

initial significant improvement in nutritional status? Dietary

improvement (quantity and quality) of individuals often has to wait

for improvement in purchasing power (hence economic development) than

public health measures which are often implemented at a stage of lower

level of development in many countries.

A question: Is it possible that successful public health measures in

the absence of economic development (or rather improved purchasing

power) may cause an increase or stagnation in malnutrition prevalence

while child mortality rates decrease? The impact of the recent

economic turmoil in certain coutries of South-East Asia on those

indicators may provide some insight.



UNICEF Madagascar

Date: Sun, 31 May 1998 08:27:39 +0100

From: Michael Golden <refugeesatabdn.ac.uk>

Subject: Ngonut: Message from David Werner


May 9, 1998

Dear André Briend,

Thank you so much for sending me your excellent article on "Child Malnutrition in Matlab: Some Key Questions." I have read it with great interest. I think the evidence you provide that small (stunted) children in the study area are not just "small but healthy" but are rather the result of undernutrition that correlates with lowered resistance to disease and higher mortality, is very important. Equally important is your conclusion that "lack of food, rather than frequent diarrhoea, is the major cause of malnutrition among weanlings in rural Bangladesh." This finding agrees with the conclusion we draw in our book "Questioning the Solution," and is especially important in the light of UNICEF's insistence that repeated infections (especially diarrhea) are the main cause of failed weight gain in young children, rather than lack of sufficient food. The implications are, of course, far-reaching. What is needed to lower child mortality is not so much a medical concern as a sociopolitical/economic one. The answer can only lie in reduction of poverty (so that all children get enough to eat) and, in the long run, in working toward fairer, more equitable social structures. Better education of doctors and mothers in ORT and diarrhea management, while important, is not enough.

The question as to why, in the study you and we have both quoted, child mortality rose in spite of apparent improvement in nutrition, still remains a mystery. Any more ideas?

Best wishes,


David Werner

HealthWrights, Workgroup for People's Health and Rights

964 Hamilton Avenue, Palo Alto CA 94301, USA

email: healthrightsatigc.apc.org, http://www.healthwrights.org