The Unfortunate Misconception of ORT

One of the leading causes of death and hospitalizations for infants and children within the global health community is attributed to diarrheal diseases. It is estimated that this preventable and treatable condition annually kills 760,000 children under the age of five. (WHO, 2013)  And from a global health perspective, there are nearly, 1.7 billion cases of diarrheal disease. (Ibid) And in developing countries, extremely high infant and children mortality rates are caused by dehydration which in turn is a major symptom of diarrheal disease. One must wonder why a treatable and preventable condition is effecting the global health community at such a morbidity and high rate.

Oral Rehydration Therapy (ORT) was created in the early 1960s to treat cholera patients in the Philippians and East Pakistan (which is also known as Bangladesh). And in 1971, ORT was identified as an effective solution in treating a diarrheal disease such as cholera during crisis situations. (Qureshi, 2010) The original ingredients of ORT combined a fairly simple mixture of sugar, salt and clean water. When compared to intravenous treatment for dehydration, ORT was considered the most cost-effective and efficient strategy in treating diarrheal diseases in both children and adults. Administering the ORT mixture did not require any medical personnel and the ingredients are considered cheap.

So why are there still high morbidity and mortality rates for diarrheal diseases among children? One issue can be credited to the lack of access to clean water in some regions of developing countries. Another cause could be related to the current health status of an individual. Malnourished and chronically ill patients have an increased risk of dying from a diarrheal disease. And while these causes are serious and require further attention, a common misunderstanding of ORT may also be a possible contributor in the morbidity and mortality rates of diarrheal disease.

While ORT is still considered an “important medical advancement” as declared by the Lancet in 1978, there are some disadvantages which may impact the utilization rate of ORT. (Ibid) One major issue of ORT is that while an individual is on the ORT regimen, they may continue to experience diarrheal symptoms. Also some ORT kits are packaged as being unflavored but there are many reports of a strong salty taste which makes it difficult to administer to children. And lastly, the various versions of ORT may confuse an individual in properly creating an ORT mixture.

While the benefits of ORT greatly outweigh the disadvantages mentioned, more attention needs to be focused on why so many children are dying across the world from an avoidable and preventable condition.

References

Qureshi, N. A. (2010). Oral Rehydration Therapy. Boston: Harvard Business School Publishing.

WHO, W. H. (2013, April). Diarrhoeal Disease Fact Sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs330/en/

No one Wants to Drink Salt and Water – the Struggle to Raise ORT Momentum

I remember being forced as a child to gurgle salt and water solution whenever I would get a mouth sore in Nigeria. The solution was never pleasant and I can’t imagine what drinking it must taste like. Even then, I always distrusted the potency of this “drug”, believing it to be an old wives’ tale and wondered why I simply wasn’t given a drug from the Pharmacy. 15 years later in New York and I often yearn for some of those “drugs” my grandmother would prescribe to me whenever I got a mild to moderate illness. It’s difficult to understand from a health specialist point-of-view why such a seemingly easy, and not to mention, effective remedy has such as slow uptake in developing countries. The Oral Rehydration Therapy (ORT) case study from Harvard Business School presents the facts, among which is the aforementioned example from my childhood, in hopes of stimulating discourse and innovative solutions.

The use of ORT as a first line treatment for diarrhea is not more widespread despite its proven effectiveness because of a myriad of interconnected issues which compound to create a negative synergistic effect that has resulted in slower than expected adoption and implementation of ORT. As is sometimes the case with global health recommendations, delivery from the country level and community/individual preferences and/or beliefs were overlooked during the first implementation stages.

I believe the first issue on the agenda for ORT scale up should be increasing demand for ORT. Currently, individuals and providers do not demand ORT because of a distrust of its effectiveness, lack of understanding of the severity of diarrhea and the challenging fact that ORT does not treat the symptoms of diarrhea (which caregivers observe), but simply prevents death from mortality (which is harder to observe unless a child is in that situation). Addressing demand issues will ensure that there will be sufficient demand in the population for ORT to be successful should the supply side issues be resolved as well. In terms of supply issues, pulling a script from the global response to tuberculosis, creating a supply committee to aid countries in understanding the logistics involved with ensuring adequate availability and distribution of ORT to those in need would help resolve some of the supply issues. Also, working with the pharmaceutical companies to create a solution that tastes better for children will ensure that children are willing and happy to use ORT.

Lastly, while encouraging homemade ORT solutions sounds appealing, there is a huge margin for error because of lack of standardization. Caregivers should be educated on the specific proportions for the solution and should be encouraged to use this first line response for when the symptoms first appear. It is not only enough to discover effective solutions to some of the world’s trying health issues, it is also important to understand what factors on the ground, sometimes health-related other times not, might affect implementation and scale up.

Marketing ORT

In 1980, diarrhea and dehydration were killing 4.6 million children worldwide. You would probably guess that when a simple, inexpensive solution came along, it would be quickly and widely adopted. Unfortunately, eight years after introduction, Oral Rehydration Therapy was only being used in 35% of diarrhea episodes. While there are numerous reasons for the slow adoption for ORT, I want to discuss the case in the context of the ORT marketing strategy. I acknowledge that businesses have the luxury of knowing that the financial benefits of marketing will far outweigh the upfront costs. While the same is true in healthcare, justifying the short-term marketing costs can be far more difficult than in business.

A central pillar of marketing is that you must “meet your customers where they are.” Meaning, your product must be distributed through the channels your customers want to use, not necessary those that are the easiest or cheapest for the distributor. To put this in context: Amazon is opening brick and mortar stores because some customers do not want to shop via the internet, and would prefer to visit a store location. Arguably, BRAC succeeded because its oral rehydration workers were visiting millions of houses, meeting care providers in their preferred locations, which removed hurdles to adoption for ORT. Admittedly, this door-to-door strategy is time intensive, expensive and difficult to coordinate. Nevertheless, it was working, and intensifying the strategy could have eliminated some of the confusion that hindered the use of ORT.

The question of bundling zinc and ORT together, or distributing them separately, is easy to answer from a branding and marketing perspective: together. Setting aside all the other challenges with zinc, customers are more willing to buy complimentary products when offered together. Moreover, not bundling products is simply a missed opportunity for a second sale, or in this case, an improved health outcome. While a costly and logistically difficult, clean water should also have been part of the bundle. How many times have you bought a toy, couldn’t use it because you didn’t have batteries? In this scenario, water is the batteries.

Finally, officials expected a viral marketing campaign based on the quality of ORT alone. Unfortunately, viral marketing requires identifying influencers and targeting them for early adoption, and dissemination. Given this, pharmacists should have been a key target in the early stages of ORT outreach. The same workers conducting in home trainings should also have been training pharmacists, religious leaders, community heads and schoolteachers.

Despite common lure, even great products do not sell themselves. ORT adoption could have been significantly improved with a more traditional approach to marketing.

Oral Rehydration Therapy and the Ebola outbreak

Diarrhea and the accompanying dehydration is the second leading cause of death in children under five worldwide. Since the early 1980s, the WHO and UNICEF have recommended oral rehydration therapy (ORT) to reduce mortality from number of diseases with diarrheal symptoms. The therapy is widely credited with preventing millions of deaths; it was adopted and utilized across Asia and Sub-Saharan Africa in the 1980s and 1990s, resulting in a decrease of 3.1 million deaths by 1999. ORT’s simplicity – it is a mix of clean water, salt and sugar – and its low cost appeared as an efficient, high-impact solution to the diarrhea issue.

The Ebola virus falls into the category of diarrheal disease and I wondered whether ORT was a part of the care for patients during the recent West African Ebola outbreak. Vaccines and targeted drugs for the disease are not fully developed yet, so the best medical advice right now is aggressive fluid replacement. Through a study of Ebola survivors, researchers learned that drinking 4 liters of rehydration solution daily is crucial.

However, it is really difficult for an Ebola patient to drink the fluids due to nausea, a common symptom of the disease. I can understand why it’s hard for Ebola patients to stay hydrated; one is simultaneously fighting to avoid vomiting and forcing a salty liquid down one’s throat. Flavoring the liquid may help. Orange-flavored granules are available and patients have said they are much more pleasant than the flavorless kind. This observation might be helpful intreating children who dislike the taste of ORS.

Dr. Igonoh drinking her orange-flavored oral rehydration solution.

“As I took the ORS and treated dehydration, it provided me with energy, and my immune system was able to battle the virus,” said Ada Igonoh, a doctor who contracted Ebola while working in Lagos, Nigeria. Nigeria has rid itself of Ebola and has suffered fewer deaths compared to other countries in West Africa. The WHO’s interviews of several of the Nigerian survivors indicated that hydration was a factor in Nigeria’s lower fatality ratio. The WHO promotes Nigeria’s approach as the blueprint for other developing countries at risk of Ebola.

[1] Diarrhoeal disease. (2013, April 1). Retrieved December 5, 2014, from http://www.who.int/mediacentre/factsheets/fs330/en/

[2] Gale, J. (2014, November 17). Beating Ebola Means Drinking,  Last Thing Patient Wants to Do. Retrieved December 5, 2014, from http://www.bloomberg.com/news/2014-11-16/beating-ebola-hinged-on-sipping-a-gallon-of-liquid-a-day.html

Global Health Law and Access To New Medicine: Ebola, Money Distribution, and The World Bank

What is Global Health Law? Global health law is a field that encompasses the legal norms, processes, and institutions needed to create the conditions for people throughout the world to attain the highest possible level of physical and mental health[1].

Global Health Law is carried out by countries and several major international agencies including the World Bank. As an investment bank, the World Bank provides technical and financial assistance to developing countries with the aims of reducing poverty and increasing development[2]. In addition to poverty and development, the World Bank has played a pivotal role in combating global health pandemics for the last 50 years.

In August 2014 the Ebola pandemic took center stage on a global platform as contraction of the Ebola virus began to escalate at an exponential rate. On August 8th, 2014 the World Health Organization (WHO) declared Ebola as a Public Health Emergency of International Concern (PHEIC). With the gravity of the impact that Ebola has had West Africa, West African governments became vocal about their need for help. The increase in viral outbreak required the leadership of international health organizations to implement solutions – including new medicine and increased access to medical care.

With the World Bank’s investments into emergency medical care, it has dramatically increased West Africa’s access to medication and medical treatment regarding Ebola. As of early November, the World Bank has mobilized nearly a billion dollars for use in the hardest hit areas in Western Africa, the largest contribution by a single-organization to combatting Ebola. The distribution of money, mostly managed by UNICEF, has provided medical solutions to thousands of people in Western Africa.[3]

There is currently no FDA-approved cure for Ebola. Several pharmaceutical companies have created trial medication to combat the disease, but the medication is not produced in large quantities nor is it guaranteed to work. While the World Bank has been able to mobilize money to provide antibiotics to treat symptoms and side effects of Ebola it has not contributed funding to finding a cure for the disease. As a result, Western countries are acting independently to find a cure through trial medicine. While West Africa has been hardest hit by Ebola, trial medication is currently only being used on Ebola patients in the US and Europe. A disproportionate number of Ebola cases have occurred within West Africa – The US and Europe have a combined total of 7 confirmed Ebola cases, while West Africa has had over 15,000 cases[4].

With the leadership role that the World Bank has taken on, it would be beneficial if the World Bank directed that some of the money acquired be used in conjunction with the WHO and Center For Disease Control (CDC) towards a cure for Ebola. Rather than just providing money towards antibiotics, putting the World Bank’s money behind finding a cure, could positively impact those that need it the most – and not just the Western world.

[1] Gostin, Taylor. “Global Health Law: A Definition and Grand Challenges.” Public Health Ethics (2008): 53-63

[2] World Bank . What We Do. 2014. <http://www.worldbank.org/en/about/what-we-do&gt;.

[3] World Bank Group Ebola Response Fact Sheet. November 2014. <http://www.worldbank.org/en/topic/health/brief/world-bank-group-ebola-fact-sheet&gt;

[4] BBC. Ebola: Experimental drugs and vaccines. November 2014. <http://www.bbc.com/news/health-28663217&gt;.

Global Patent Law is an obstacle for the Developing World

In the publication “TRIPS and The Global Pharmaceutical Market”, Barton describes the effects of the Trade-Related Aspects of Intellectual Property Rights agreement on the global community. Access to medicines presents a conflict between the interests of social justice and the pharmaceutical industry’s interest in economic prosperity. By the end of this article, I was disappointed but not surprised to reach the conclusion that TRIPS protects private profit without as much consideration for the health needs of disadvantaged populations.

The patent system’s purpose is to permit an elevated price to fund research and development (R&D). TRIPS was put into place to extend patent protection. It required all World Trade Organizations to follow well-defined guidelines of intellectual property protection. The developed world readily accepted the agreement. The royalty costs to the developing countries would be greater, but in exchange, concessions were to be made that would expand the developing countries’ exports. In the late 1990s, NGOs became concerned about the detrimental effect TRIPS might have on developing countries. Patent law led to increased prices for pharmaceuticals, especially the prices of antiretrovirals used against HIV.

Dissent from individual countries led to compromise on pricing of drugs. Brazil could not keep up with the rising prices of imported medicines and threatened to grant compulsory licensing to allow production of medications under patent within the country. In 2001, differential pricing for poor countries and rich countries was introduced to appease developing countries. As it turns out, lower pricing does not improve access to medicine for patients suffering from HIV/AIDS in developing countries. The total amount of global health funds available are not sufficient to provide drugs for all the epidemic diseases, even when the drugs are available at low prices.

Disadvantaged populations do not reap the benefits of innovation. There is a lack of incentive for the drug industry to develop new drugs for the developing world’s market because this market has a limited magnitude. Simply put, there is no money to be made in the markets of poorer countries, so why incur costs of R&D for little returns?

The global patent law agreements have had the most impact on developing countries, but the United States should anticipate some impact as well. Developed countries such as the U.S. must prevent the low-priced products from being imported to the developed world. These imports would cut into this patent-protected market. To protect the developed market, the pharmaceutical industry has created ways of distinguishing low-cost drugs intended for developing countries by packaging and color.

This article raised an interesting point. How will Americans react when they discover that a drug is available to others at a far lower price? Yes, the people receiving the medicines at a discount are much less fortunate than we are, but the humanitarian angle is not a sufficient excuse for the price difference. The government and pharmaceutical companies will face political backlash. I do not think that the U.S. is currently capable of subsidizing pharmaceuticals to please the public. The coverage of pharmaceuticals  would be difficult to include in the Affordable Care Act. Alternatively, the U.S. can move toward public control of the drug prices and negotiated prices.

The article was written to discuss a global issue, throughly presenting each stakeholder’s vantage point. I had not been aware of the politics of patent laws as it pertains to the drug industry; the article did a great job of summarizing the issues and the history.

Let’s tap into the potential of the Human Rights Framework

Dilemmas in decision-making are invariably apart of global health policy. With the variety of international actors, stakeholders, and opinions, it’s easy to see why implementing new global health policies, through ingenious and innovative, are hindered by the stalemate that is governmental bureaucracy and political agendas. However, there potentially exists a framework to navigate around these highlighted challenges – human rights.

“The right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”

This statement is echoed in the International Covenant on Economic, Social, and Cultural Rights, a major component of the modern day definition of human rights. The multitude of human right documents establish concepts around the “minimum acceptable standards of health” by which all member countries should abide by in practice. The existing human rights framework provides a reasonable and coordinated framework the international community needs to fully adopt in times of global health responses and dilemmas. In many instances, the norm is to do the opposite however. It is at best questionable whether human rights has a defining impact on governmental practices, as Gostin and Sridhar note in a NEJM May article.

Slow international public health responses are the direct outcome of this, most recently from the Ebola crisis affecting West Africa. Prominent individuals, actors, and organizations have been critical of the WHO’s response to the Ebola epidemic, notably, Peter Piot:

“It’s the regional office in Africa that’s the front line,” “And they didn’t do anything. That office is really not competent.”

The potential of the human rights framework is shown here – a more robust implementation of the human rights framework, and more generally international human rights law, can directly change this. Currently, there are too many barriers which limit the potential human rights can effectively serve the international community – including governmental desire to maintain governance power and weak enforcement practices on behalf of the WHO to ensure international compliance with global health law standards, including human rights.

The significance and influence of the human rights framework is shown in it’s unique link to the health and well-being of individuals in practically all aspects of day-to-day living. From denying individuals the “right to specific information” or the right to live under “just and favorable conditions” (UDHR, Article), a country that fails to uphold human rights will fail to achieve improved health standards. What’s missing is the complete acknowledgement of the international community of this realization and the overall importance of human rights.

What needs to happen is a reevaluation and revamping of administrative mechanisms which the WHO utilizes in reviewing, broadcasting, and implementing human rights to the rest of the international community – maybe this calls for an entirely new enforcement body perhaps? What needs to be ensured is that the potential of the human rights framework to implement change in global health policy must not be wasted – rather it should serve as an impetus to drive forward change in this ever complicated and dynamic field of global health policy.

Is Disease Eradication Possible In The Age Of Patents?

After reading about attempts to eradicate Polio in Uttar Pradesh, followed by several articles addressing the Trade-Related Aspects of Intellectual Property Rights (TRIPS), I was curious: Did the United States use a patented vaccine in its polio elimination campaign? The short answer is no.

This question was prompted by (what I guessed to be) an analogues situation in economic development. In the late 1990s and early 2000s, many economists promoted market liberalization as a pathway for economic development. Many rationalized this practice by pointing to the current economic policies of the United States, and its economic growth. Essentially, the prescription to developing countries was – make your economic policy reflect that of the United States, and economic growth will follow. However, this overlooked, or intentionally ignored, the fact that the United States utilized intense protectionist policies in its infancy, incubating domestic industries and enterprises before ever exposing them to intense international competition. There was no empirical evidence that market liberalization could promote economic development.

While disease reduction is a noble cause, I question if we are asking middle and low-income countries to execute an impossible task. To some extent, the current dialogue highlights the United States and says to developing countries, “if they could do it, so can you” – despite the fact that the rules of the game have changed drastically.

The March of Dimes “committed to give the formulation and production processes for the vaccine to several pharmaceutical companies for free,” ensuring that the polio vaccine could be produced cheaply, and in mass. Interestingly, patent law existed, but lawyers did not believe they could patent the Salk vaccine. Today, most vaccines are patented and expensive. ” In this context, one could argue that the recent decisions and threats by India and Brazil, respectively, are only attempts to recreate the same environment in which vaccination campaigns have been financially and operationally feasible in the past.

With patent law intensifying since the American polio eradication campaign, the United States Government has adapted. “The U.S. government is now the primary applicant for vaccine-related patents, followed by GlaxoSmithKline and a number of other corporations.” With the government as a competitor in drug development, it is possible that the public sector will develop new remedies funded by taxpayer dollars, enabling inexpensive distribution. However, this still leaves low and moderate-income countries out of the loop. Low-income countries have small tax and limited bandwidth to support such research – leaving them tied to patented drugs, and the support of NGOs.

To date, the only globally eradicated disease is smallpox. The original vaccine for smallpox did not have a patent. Without a significant shift in patent policy, utilizing vaccines to eradicate diseases appears to be an impossible task for low and middle-income governments to undertake on their own.

Both quotes from: http://www.slate.com/articles/technology/history_of_innovation/2014/04/the_real_reasons_jonas_salk_didn_t_patent_the_polio_vaccine.html

Polio Elimination in Uttar Pradesh – Individual impact in global health policy

The case of Polio Elimination in the Uttar Pradesh state in India serves to highlight the impact that specific individuals can have in any global health undertaking. Likewise with the smallpox elimination program administered in Africa as well as in India, individual will power serves as a great instigator and spur of driving action in global health policy – in this case of Polio eradication.

The theme of individualized leadership in global public health campaigns is signified through the work of two individuals throughout the course of the Polio Elimination program in Uttar Pradesh – Dr. Kaushik Banerjee and Dr. Jon Andrus.

The efforts of these two individuals quickly made in roads in the Polio fight in Uttar Pradesh. With collaboration with Global Polio Elimination Initiative (GPEI), a coordinated public health program compromising of Rotary International, WHO, the CDC, and UNICEF, Banerjee and Andrus were able to help establish a National Immunization Day (NID). The program helped foster greater immunization rates amongst children, and polio outbreaks in India became more localized. However, coverage gaps still existed amongst the northern portion of India, prompting Banerjee and Andrus to present a case for increased immunization rounds in India to six rounds in the North and four in the south, relying in surveillance data to augment their argument.

What became know as the 4+2 program, the impact was significant on India’s polio outlook – polio cases dropped from 1,126 in 1999 to 265 in 2000; however, a majority of these cases, over 200, were concentrated in the Utter Pradesh state, for a multitude of reasons – climate, public health conditions, etc. Ultimately, the success of the program was hinged on the arguments and persistence of Banerjee and Andrus.

When the pair left their respective posts within the Polio Elimination campaign in the summer of 2002, the Indian government decided to scale down it’s polio response within the northern region, using just two national and regional immunization days – which was against the recommendations of Banerjee and Andrus. In 2002, India Suffered a polio outbreak, and 1,600 Children came down with paralytic polio, including over 1,200 cases in the Uttar Pradesh region alone. This incidence found that past immunization campaigns were not robust enough in their strategies, leaving a “pool” of unvaccinated children contributing to the outbreak.

The main talking point here revolves around the significance and displays of influence Banerjee and Andrus held towards the Polio elimination campaign in Uttar Pradesh and India overall. Once their opinions, perspectives, and arguments were no longer voiced, the Indian government immediately took retroactive steps in the Polio elimination campaign. Likewise to an extent to the smallpox global eradication program, although many international and national organizations and institutions were behind this public health campaign, the realization of the elimination of Polio in Uttar Predesh is fundamentally tied to the efforts and insights of a few particular individuals. I feel it’s quite interesting to find such a relation – that problems so inherently tied to the well-being of millions individuals can rest on the capabilities of just a few individuals in global health policy.

Polio, a disease of cultural and religious differences?: a look into polio in Nigeria

Northern Nigeria is plagued with many issues, one of them being Polio. Nigeria, along with Afghanistan and Pakistan are the only countries left in which Polio is still endemic. Considering that Polio has been eradicated in most of the world, this fact is quite disheartening and begs the question: Why hasn’t Polio been eradicated in these countries? Unfortunately, the answer to that question is more complicated than simply providing vaccines to the respective populations.

Interestingly, these marginalized populations are Muslim. An interesting fact that was also observed in Uttar Pradesh, India. That is not to say that Islam is a major factor affecting polio eradication. It simply is a commonality shared by different populations affected by the same disease and begs the question: Are these people being marginalized by their government as a result of other cultural and religious tensions? This is the question that I attempt to shed some light on.

Nigeria is arguably divided 50/50 by Christianity and Islam with the south being predominantly Christian and the north being predominantly Muslim. Data shows that northern Nigeria is disproportionately affected by poverty and health issues when compared to southern Nigeria (for instance, higher rates of malaria, cholera, poverty, malnutrition, hunger, etc). To combat these issues, national efforts have focused largely on vertical approaches to these public health issues, which was the approach taken to eradicate polio via the Global Polio Eradication Initiative (GPEI). However, there has been a current shift in global health trends to health systems strengthening as a new public health approach. Also, the failure to eradicate polio in countries such as Nigeria further heightens the need for this approach and the need to comprehend the underlying issues exacerbating the spread of polio.

As mentioned, northern Nigeria is plagued by many issues, most of which is intertwined with the recent insurgence of Boko Haram. It is difficult to use a strictly vertical approach to scale up polio efforts when a huge influence on the community, Boko Haram, continually thwarts these efforts. Due to the presence of Boko Haram, there has been an increase in distrust of the government and deteriorating security, compounded with low levels of education creating a melting pot that is ripe for continued spread of the disease.

Despite these set backs, the number of cases in Nigeria has dropped indicating that is it possible to eradicate the disease once and for all. Also, Nigeria’s successful elimination of Ebola shows that the government is capable is responding swiftly and effectively to public health issues. However in order to replicate this success in polio, Nigeria would need to scale up polio immunization efforts by increasing community engagement and use of community health workers and integrating polio vaccination to other immunization efforts and possibly maternal and child health treatment cascade as a whole.