An Affordable Diarrhea Treatment Could Save Thousands of Children's Lives


May 15, 2024

A mother brings her malnourished baby to the Child In Need Institute emergency ward in Kolkata, India, June 4, 2009, photo by Andrew Aitchison/Alamy

A mother brings her malnourished baby to the Child In Need Institute emergency ward in Kolkata, India, June 4, 2009

Photo by Andrew Aitchison/Alamy

Nearly half a million children succumb every year to one of the most prolific killers on the planet: diarrhea. A small packet of salts and sugar—retail price, a few cents—could save most of them. Yet health care providers around the world continue to prescribe antibiotics instead, to fight a disease that antibiotics usually won't touch.

Researchers at RAND have been working for years to better understand why. In a recent study, they hired actors in India to pose as worried parents seeking care for a sick child. They found that health care providers often ignored the rehydrating salts—not because they didn't think the salts would work, but because they didn't think parents would want them.

“It would be like if you went to a health care provider and they said, 'Oh, here, just take some Gatorade,'” said Zachary Wagner, an economist at RAND who led the study. “The providers just generally thought parents were there for something stronger, a 'real medicine.' That's something we can work with to design better interventions. Almost no kids should be dying from this.”

In 1971, as war raged in what would become Bangladesh, millions of people fled across the border into India. Cholera soon swept through the overcrowded refugee camps. A visiting doctor described people lying on cots or on the open ground, too weak to get up. But, he wrote, “I was amazed by what I saw.”

Parents, grandparents, spouses, and friends were tending to the sick with cups of liquid taken from central drums. The liquid contained a mixture of rehydrating salts and glucose, or sugar, to help the body absorb them. The death rate could have been as high as 30 percent under the conditions at the camp, the doctor noted. Instead, it was closer to 3 percent.

Diarrhea kills by dehydration. The discovery that salts plus glucose and water can keep people alive has been hailed as one of the greatest medical advances of the past century. The mixture is now widely available in low- and middle-income countries, often sold in small packets with fruit flavors to mask the notoriously bad taste. Yet study after study has found that medical providers from south Asia to sub-Saharan Africa just don't use it enough.

A packet of oral rehydration salts, photo by Simon Berry/CC BY-SA 2.0

A packet of oral rehydration salts

Photo by Simon Berry/CC BY-SA 2.0

Wagner and his team designed their experiment to test several theories at once for why that is. They recruited dozens of actors in India and had them pretend to be parents seeking help for a 2-year-old child. Then they sent the actors to visit the same private health care providers that most parents in India would use: medical doctors, but also untrained rural clinicians, practitioners of traditional medicine, and pharmacists.

Maybe, the researchers thought, the problem was one of supply. They sent boxes of salt packets to clinics and pharmacies across two states in India. But the likelihood that those providers would then recommend the salts to one of the actors posing as a parent increased by only a few percentage points.

Maybe providers had a financial stake in selling more expensive medicines. The researchers had some of the actors say they were just looking for a referral and would buy whatever medicine they needed elsewhere. That eliminated any financial incentive—but, again, it only increased overall salt prescriptions by a few percentage points.

But then the researchers had some of the actors specifically ask for rehydrating salts by name. And when they did that, prescription rates nearly doubled.

“We were very surprised,” said Arnab Mukherji, an economist at the Indian Institute of Management Bangalore, who coauthored the study. “Generally, the doctor is seen to be someone who's giving you advice, thinking about all of the variables and giving you what's best for you. We didn't expect to see such a large change in behavior when patients nudged them.”

But that still didn't answer why providers were hesitant to prescribe salts in the first place. To find out, the research team surveyed more than 2,000 of those same providers. Almost all of them—86 percent—said they knew oral rehydrating salts were the correct treatment for a 2-year-old child with a simple case of diarrhea. But the salts don't cure diarrhea; they only keep patients alive long enough to recover. The providers thought their patients wanted something more.

That's a potentially fatal misperception. The researchers also surveyed 1,200 Indian families that had recently sought care for a child with diarrhea. The families were more than three times more likely to say they wanted rehydrating salts than antibiotics. But only 16 percent spoke up and expressed that preference to their provider. As a result, a majority of them went home with an antibiotic, not rehydrating salts—not even to take along with the antibiotic.

Provider perceptions that patients do not want oral rehydration salts (ORS) are the most important barrier to ORS prescribing

Bar chart showing the status quo of ORS prescribing compared to three other scenarios

See paragraph below for description of bar chart information.

If all of the caregivers had requested rehydrating salts, the researchers estimated, the prescription rate would have jumped from around 42 percent to 67 percent. Eliminate supply shortages, and it would tick up to around 70 percent. Take away financial incentives to sell other medicines, and it would bump up again, to around 73 percent. That would save a lot of young lives.

“Providers might think that patients are just going to get rehydrating salts someplace else—but they don't,” Wagner said. “If the provider doesn't prescribe it, they're very unlikely to use it. And patients usually aren't going in and saying, 'Hey, I want this.' It could be considered disrespectful, like telling the providers you know better than them. We need to find a way to change that.”

That could be as simple as a poster hung up in a pharmacy, telling patients to ask for rehydrating salts instead of antibiotics. Providers thought that would give them more credibility when they prescribe something as simple and basic as a packet of salts. The research team also hopes to pilot a WhatsApp campaign that would send phone messages to parents of young children, encouraging them to speak up and ask for the rehydrating salts.

The research team, which also includes experts from Duke University and the University of Southern California, hopes to repeat the experiment in sub-Saharan Africa. Diarrheal diseases are an even deadlier problem there, and salt use is just as low.

“It's always been mysterious to me why, when we have something like rehydrating salts, diarrhea continues to be the second- or third-largest source of mortality, especially for children,” said Mukherji, a Pardee RAND Graduate School alum. “This opens up a whole array of options to nudge doctors and patients to change that.”

His young son got sick not long ago. It wasn't a diarrheal disease, but another virus that left him feverish and weak. The doctor thought he might need to be hospitalized—but decided to try a course of rehydrating salts first. “We were frantic,” Mukherji said. “He was just flat on his back. But we gave him the rehydrating salts, and he perked up significantly. After a few days of that, the fever broke. And then he was able to get back to being all over the place.”