The Power, and Process, of a Simple Solution

By Amy Yee
Originally posted on New York Times

Khulna, Bangladesh — On a hot morning in southern Bangladesh, an hour from the port city of Khulna, parents with small children waited at a three-room clinic set amid bamboo groves and jackfruit trees. The children’s ailments ranged from coughs to eye infections, but none were there for diarrhea, even though it is the world’s second-largest killer of children under age five, after pneumonia.

Shamim Parvez, a doctor at this free clinic in Paigram Kasba village that is run by the homegrown Naifa Maruf Foundation, paused while consulting a mother and her sick toddler. “Diarrhea is not a big problem now,” he said from his seat beneath a whirring ceiling fan. “Everyone knows O.R.S.”

O.R.S. refers to oral rehydration solution — a simple but life-saving beverage of water, salt and sugar formulated in the late 1960s by American and Bengali doctors and researchers working in Dhaka, the capital of Bangladesh. Unlike saline intravenous drips to treat severe dehydration from diarrhea, O.R.S. was inexpensive, did not require special, sterile equipment and could be made at home. The potential of O.R.S. in poor countries was enormous.

Indeed, in the last 30 years, O.R.S. has saved an estimated 50 million lives worldwide, particularly children, who are most vulnerable to diarrhea-related dehydration. In 1978 the British medical journal The Lancet called the humble solution “potentially the most important medical advance of the 20th century.”

O.R.S. has undeniably helped Bangladesh make big strides in improving child health in recent decades. Diarrhea caused 2 percent of deaths of children under age five from 2007-11, compared to almost 20 percent in 1988-93, according to the 2011 Bangladesh Demographic and Health Survey. About 78 percent of children with diarrhea have been treated with O.R.S. since 2007.

Indeed, reducing death from diarrhea helped Bangladesh last year become one of only eight countries to have reduced mortality rates of children under five by at least two-thirds since 1990, in accordance with the United Nations Millennium Development Goals.

Despite the product’s humble origins in Bangladesh more than four decades ago, UNICEF today distributes 500 million sachets of O.R.S. to 60 countries each year.

While the success of this health initiative is cause for celebrating, it’s worth remembering that it took many years and various changes in strategy to get people in Bangladesh to use something as simple as O.R.S.

Solutions to social problems tend to focus on products, a rush to scale up and buzzwords like “innovation.” But systematic processes to spark change are another essential, though often overlooked, ingredient. “Innovation is overhyped,” declared the website of a “Frugal Innovation” conference organized by BRAC last year in Dhaka.

BRAC, the non-governmental organization formerly known as the Bangladesh Rural Advancement Committee, is the world’s largest NGO in terms of number of employees, and was critical to the spread of O.R.S. in Bangladesh and beyond. In a soft-spoken voice, Sir Fazle Abed, BRAC’s white-haired, 78-year-old founder and chairperson, explained that management and monitoring systems have to be in place before scaling up. “Some NGOs don’t have processes and systems,” he told me matter-of-factly last year during a visit to New York, where he was speaking at the Clinton Global Initiative. Organizations have to be “effective and efficient and then you expand.”

BRAC was a pioneer of systematic processes in the developing world. In 1980 BRAC launched a program in Bangladesh called “OTEP” — Oral Therapy Extension Program — to teach mothers in very poor, rural communities to make oral rehydration solution at home. Through simple but rigorously monitored methods, illiterate women learned to make the solution with common home ingredients — a pinch of salt, a handful of sugar and clean well water. In the next decade, BRAC trained more than 12 million women in Bangladesh to make O.R.S., and saved countless lives.

Bangladesh today has the highest use of O.R.S. in the world. BRAC hopes to spread awareness of the electrolyte solution in parts of sub-Saharan Africa where use is still spotty. BRAC, which has grown globally, is well-established in Sierra Leone, Liberia, South Sudan, Uganda and Tanzania and is looking for partners who can expand use of O.R.S. there just as Bangladesh did in the 1980s.

While it is easy to take O.R.S. for granted today, there was no guarantee in the early years that it would become a widespread home remedy. After doctors and researchers came up with the correct formulation, how would they get poor households in Bangladesh to actually use it? The groundbreaking salt-sugar-water formulation was not enough. Scrupulous systems, monitoring and testing to track what worked and what didn’t in rustic environments were critical.

Mr. Abed recalled some of the early challenges of spreading O.R.S. among people in rural Bangladesh. In the 1970s, NGOs tried to distribute O.R.S. packets but Bangladeshis didn’t realize they had to mix the powder with water. In any case, sachets were expensive at the time and thus impractical for widespread use. People were also distrustful of new treatments and clung to superstitions.

There was a big “know-do gap’’ early on, recalled Richard Cash, an American doctor who helped formulate O.R.S. in 1968, when he was in his late 20s and doing research at what is today the International Center for Diarrhoeal Disease Research, Bangladesh. Translating something from the lab “into something practical to use” in poor communities was a huge challenge, he added.

Mr. Abed of BRAC oversaw the initial pilot program that tested how women were taught to make O.R.S., although he had no experience in public health. He studied naval architecture at the University of Glasgow, trained as a chartered accountant in London and returned to Bangladesh in 1969 to work at Shell Oil. But after a devastating cyclone killed 450,000 in Bangladesh in 1970, Mr. Abed founded BRAC to help the rural poor recover from disaster. He left corporate life but brought some of those skills to BRAC, including his focus on meticulous methods.

When BRAC eventually focused on reducing diarrhea it concluded that it would have to train people from the community to teach mothers how to make O.R.S. at home. The World Health Organization had serious reservations about promoting a homemade solution but there simply weren’t enough doctors or other trained personnel to reach millions of households in rural Bangladesh. And of course, this was well before the advent of computers, spreadsheets and biometric devices that make monitoring much easier today.

So how did BRAC tackle this daunting challenge? A three-month field trial in 1979 tested whether mothers recalled BRAC field workers’ instructions on how to prepare O.R.S. This was no easy task considering that poor, illiterate households did not have measuring spoons or cups.

BRAC’s verbal guidelines included the dangerous symptoms of diarrhea, when to administer O.R.S. and how to make it with a three-finger pinch of salt, a handful of sugar and a half liter of water. In another critical step, monitors returned to villages days or weeks after the initial instruction to quiz the mothers. Health workers were paid according to how many questions their subjects answered correctly, thus incentivizing quality instruction and not just the number of lessons. The trial found that verbally trained illiterate and semi-literate rural mothers could make properly formulated O.R.S. that passed laboratory tests.

A second pilot program reached 9,000 women and BRAC further refined its teaching methodology. It found that to maintain high-quality instruction, health workers should be limited to teaching 10 women a day.

BRAC sent field workers to talk to mothers one on one, as described by Atul Gawande in his 2013 article for The New Yorker. But there was more that accounted for the program’s success.

Mr. Abed identified other early hurdles that slowed the adoption of O.R.S. by mothers. After inquiring about slow adoption in some villages, he found that only a fraction of health workers believed in O.R.S. themselves; they didn’t even use it to treat their own diarrhea. To dispel doubts among trainers, BRAC brought them from the field to research labs in Dhaka to scientifically show how O.R.S. worked. Health workers were then advised to convince distrustful villagers by sipping O.R.S. during household training sessions.

After this breakthrough, adoption of ORS increased but then plateaued. Again, Mr. Abed tried to find the root of the problem. He enlisted anthropology students in Dhaka to interview people about why they weren’t using O.R.S. They found that men were alienated from the discussions between female health workers and mothers and so withheld support for O.R.S. In villages, “we had to take men into confidences so we told them exactly how O.R.S. worked,’’ Mr. Abed recalled. When men were included in discussions, adoption of O.R.S. increased significantly.

As the program continued to grow, BRAC constantly monitored results and tweaked practices. One challenge was to check the monitors’ work to make sure they were actually going to villages and speaking to mothers and not simply “falsifying results from a tea stall,” as Mr. Abed put it.

Health workers were required to note the name of a mother’s youngest child in records that monitors couldn’t see. On separate visits, monitors also noted the name. Then area managers checked if both sets of names matched. After implementing this check, 37 monitors were fired for fabricating results. “Unless people are checked, they become sloppy,” Mr. Abed said.

The O.R.S. program eventually reached millions of households, but BRAC still ensured quality monitoring. Supervisors oversaw six to eight people, and never more than 10.

O.R.S. became so ingrained in the country that folks songs about preparing it spread. Today, the price of O.R.S. sachets has fallen so that the inexpensive treatment is readily available at shops and clinics across the country.

Now the task ahead is to get more people in countries like Sierra Leone and South Sudan to use O.R.S. and follow the model set by Bangladesh, where millions of lives have been saved by this seemingly simple solution.

Posted on April 14, 2015 .