When Imodium is the Enemy

On August 16, 2012, in child mortality, diarrhea, by Karen Grepin

It turns out that I am a much more adventurous eater than my Newfoundland gastrointestinal heritage has equipped me to be. This predicament has gotten me into a bit of trouble in the past: a much slower than originally anticipated hike through the Dogon Country, the *very* long flight back from Addis via Cairo, and my glamorous tour of gas stations in Togo and Eastern Ghana. You’d think I would know better than to eat raw meat in one of the countries with the lowest rankings on the human development index?? Apparently not. This problem has, however, forced me to develop a pantomime which has proven nearly universally effective to purchase Imodium in nearly a dozen of different countries. Imodium is my Friend.

But in the context of global health, Imodium is actually the Enemy. Diarrhea is the second most important killer of children under the age of five. The challenges of addressing this issue are complex:

1. Diarrhea is a common ailment that affects the vast majority of children on a regular basis so new cases rarely send parents rushing their kids off to the doctor. It is a fact of life in most developing countries.
2. Most cases are self regulating so if a parent does not treat or incorrectly treats their kid, this health seeking behavior is usually reinforced.
3. Most treatment is done at home so few cases are properly diagnosed and seeking advice from a medical professional is rare.
4. And finally, there are many cheap, readily available treatments.

While at first glance, this last challenge might not seem to be a bad thing, in the context of diarrhea it can be just that. There are many potential treatments being peddled for the treatment of diarrhea – from my trusty loperamide to the omnipresent antibiotics to my mother-in-law’s favorite: rice. When a child gets sick with a severe case of diarrhea, the World Health Organization and other agencies endorse the use of one treatment: oral rehydration therapy in combination with zinc. Some experts have list this intervention among the most cost-effective health interventions available yet I am sure many of you had not even heard about it. And the proportion of children with cases of diarrhea who are actually treated with this combination is abysmally low.

A new blog post by Oliver Sabot from the Clinton Foundations’ Health Access Initiative highlights how challenging this task can be in India, the country with the largest burden of diarrhea in the world. He writes on a the PLoS medicine blog this week:

Children are being treated for diarrhea, but they are just getting the wrong drugs. In most cases, the antibiotics and anti-diarrheal drugs that are the typical response to childhood diarrhea in India (given to roughly 60% of children with diarrhea) are at best useless and at worst actively harmful in most cases. Drugs like Loperamide work by paralyzing parts of the gastrointestinal tract, stopping everything – good or bad – from flowing out. For young children, this effect can be deadly: the drug was actively discouraged for use in children after six Pakistani children died in 1990 and a recent analysis found the drug caused severe side effects or death in around one percent of children. Yet mothers – and most health providers – here are not aware of these threats; they see only that the diarrhea decreases as they hoped and so drugs like these continue to do good business across India while less than two percent of children receive the recommended combination of zinc and ORS.

So how do we change this situation? I know Oliver and others (myself as well) have been working on developing some research projects that are aimed at trying to answer these questions. There are likely lessons to be learned from the recent experiences in trying to scale up the use of ACTs for the treatment of malaria (luckily Oliver was a big player in that process as well) but the challenges for diarrhea are also likely unique to this disease. But solving these questions has to be a much bigger priority if the world does actually hope to reduce child mortality in the developing world.

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8 Responses to “When Imodium is the Enemy”

  1. Beth Anne Pratt says:

    Why don’t you check out this operational trial presently underway in Zambia: http://www.colalife.org Its generated a lot of interest from UNICEF, CHAI and a number of other organizations. The Zambian Ministry of Health also is very excited about it. I should add here too that – in spite of the name – there is no relationship to Coca Cola, either the product or the company…the trial just utilizes the secondary sub-district supply chains branching out from the wholesalers who contract to the main bottling company here Zambia. The point is to utilize rural private sector retailers to deliver innovative antidiarrhoeal kits, thereby bridging the “last mile” between the community and the rural health facility.

  2. Brett Keller says:

    when kids get treatment, but it's the wrong kind >> When Imodium is the Enemy, by @KarenGrepin http://t.co/khTrVxhD

  3. Meena Nabavi says:

    when kids get treatment, but it's the wrong kind >> When Imodium is the Enemy, by @KarenGrepin http://t.co/khTrVxhD

  4. I know the feeling well.

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