Water, Salt, and Sugar

Nice, brief origin story of Oral Rehydration Salts and their deployment in Bangladesh. In particular, I enjoyed the parts describing the challenges of translating the science into practice in the field. Many of the lessons are relevant to our work in household energy and health.

  1. Use competent, well-trained field workers — and figure out clever ways to incentivize good, thorough work.

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.

  1. Ensure that field workers believe in and, when appropriate, use the items and practices they are promoting.

[Mr. Fazle Abed, BRAC’s founder and chairperson] 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.

  1. Don’t ignore the men, who have disproportionate sway over household decisions in many parts of the world.

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.

Obviously not a perfect analogy. ORS is curative — a response to ill-health — and requires a change in treatment behavior. Arguably the need for ORS decreases in a world with adequate access to clean water and sanitation — but absent that panacea, removing barriers to affordable, easy treatment is essential. The shift we seek to encourage, towards clean cooking, is meatier — it requires big changes to routine behavior. The lessons above still hold, though. We need field workers who believe in the interventions (and, conversely, interventions worthy of their belief), we need to compensate them well, and we need buy-in from whole communities.

Tags: cookstoves, energy, health, household air pollution

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