Diarrhea is second only to lower respiratory tract infections (LRIs) as the leading cause of mortality in children under 5 in low and middle-income countries. Prevention of death from dehydration became a high priority of the WHO and UNICEF, and ORT was identified as a highly effective therapeutic modality. By the 1980s, ORT programs had been launched in 90 countries.

Egypt, for example, received a 10 year, 32 million dollar grant from USAID for widespread education campaigns and subsidization of mass-produced, oral rehydration solution (ORS) packets. Mortality from diarrhea in the under 5 dropped by over 50%.

What type of program is this?

Was it effective?

Would you think that ORT would be cost-effective?

Do you think it is sustainable?

In 1991, USAID’s subsidy ended; at the time, the Egyptian Health Ministry was already having difficulties shouldering the costs of primary care programs. The MOH decided to make the program sustainable by selling ORS packets at a cost, and the price tripled (from 0.5 Egyptian pounds to 1.5 EPs), with a subsequent fall in use of ORS packets from 50 to 23%. ORT of any kind fell to 34%. Supplies also became less reliable than previously.

What would have been a more sustainable approach for this national diarrhea program?

Diarrhea can also cause massive loss of life in complex emergencies. In 1994, a cholera epidemic struck the Rwandan refugee camps in Goma, Zaire. Reports indicated up to 2000 deaths per day, with many people receiving no rehydration therapy during their illness. Early efforts to distribute 20 million packets of ORS were disorganized and ineffective. Ultimately, rehydration centers were organized with reduction in CFR from 24% to 2%.

What do you think were the distal and proximal causes of high mortality rates from cholera in this setting?