The killer no one mentions

Arthur Caplan

April 16, 1993|By Arthur Caplan

GOT any idea what is the biggest killer of children in the world today? It is not AIDS. Nor is it whooping cough or typhus. Accidents are not the culprit, either.

It is a medical problem that is almost never mentioned in polite company -- diarrhea.

Sixty thousand kids die every day from this ailment. Five million babies and young children will die this year as a result of dehydration caused by diarrhea.

What you and I know about diarrhea is almost entirely a function of the tidal wave of commercials on TV and radio aimed at getting us to buy stuff at the drugstore to treat what the ads often tactfully call "indigestion" or "upset stomach." You know, the irritated tummy that everyone is troubled by at one time or another.

In rich nations, diarrhea is a vaguely amusing, embarrassing disorder associated with eating and drinking too much (or with Mexican vacations). But, as David Werner makes clear in a short but important article in the April issue of the journal Pediatrics, in poor countries diarrhea is no joke.

The inability of the nations of the world to figure out ways to get known treatments to the millions of kids who die is one of the great ethical failures of humankind.

Dr. Werner points out that for most of the world diarrhea is a problem that is the result of starvation, bad nutrition and poor sanitation. When children do not get enough to eat, their digestive systems go haywire, and diarrhea is the result. The loss of water and important chemicals from the body causes the heart to fail and the kidneys to shut down. In too many places in the world a baby with diarrhea has a fatal illness.

There are, Dr. Werner says, two strategies for treating poor, starving kids with diarrhea. Both involve what is called rehydration therapy -- getting water, salts and necessary chemicals back into the child as quickly as possible.

Fast rehydration can be accomplished by providing children and their families with what are called oral rehydration packets. These packets contain premixed amounts of glucose, salt, potassium and other chemicals that can quickly get the body's chemistry stable.

The other way to get a baby's body back in balance involves supplying the same chemicals in a form that can be added to the food or drink that families normally consume. Home mix can be prepared by a mom or dad and given to a child in traditional foods, such as porridge, rice water, soup, gruel or drinks.

Both methods cure kids. Some experts, governments and international aid programs favor giving out pre-mixed, self-contained packets. They believe that this is the safest and most reliable way to get the right mix of chemicals to a child in need because the packets leave no room for error or contamination.

Community health workers, such as Dr. Werner, argue that home mix is better because it is easier to keep on hand and easier to supply in nations with underdeveloped systems of communication and transportation, and it makes the parents feel more involved in caring for their child.

There is another key difference between pre-mixed packets and home mixes. Packets cost more. A family earning 50 cents a day may not have the 15 or 20 cents to spare to buy a pre-mixed packet. Mixes cost only pennies.

Dr. Werner worries that the companies that are in the oral rehydration packet business have far more incentive to push packets than mixes.

The fact that, according to the World Health Organization, multinational drug companies last year sold $50 million worth of absolutely useless medications in poor countries for treating diarrhea in malnourished children lends support to the view that the bottom line may have more to do with the preference for packets over mixes.

The obvious solution to the epidemic of death caused by diarrhea in babies and young children is to solve the problem of malnutrition by making sure kids everywhere get enough to eat.

But until that goal is achieved, the nations of the world ought to rededicate themselves to making sure that no child dies of diarrhea. They do this by providing the safest, cheapest, most effective cure available -- home rehydration mixes.

Arthur Caplan is director of the Center for Biomedical Ethics at the University of Minnesota.

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