Why is oral therapy associated with drugs in the treatment of diarrhea?

Abstract

To the Editor: In a recent issue of this journal, J. M. Rhoads (1) reviewed recent clinical trials on the treatment of acute watery diarrhea in children. He reached the conclusion that pediatricians now have “several options for treating infants with significant diarrhea after oral rehydration.” We could pursue the discussion by asking, Why is oral therapy associated with drugs in the treatment of diarrhea? In 1990, the World Health Organization (WHO) published a note (2) on the rational use of drugs in the management of acute diarrhea in infants and small children, indicating that almost 90% of the children who come to health care centers presenting with watery diarrhea may be successfully treated with only rehydration and food intake. Antibiotics and antiparasitic drugs should be prescribed only in some very specific cases. In fact, rehydration is the only therapeutic method that has proved to be efficient. Taking its low cost into account, savings resulting from its use should be quite important. We conducted a pilot study during two periods in which the observation of diarrheic episodes was easy; it took place in July-August 1990 in Oran (Algeria), in two clinics and in a specialized unit (2). It was then observed that oral rehydration salts (ORS) are rarely or never prescribed by some physicians and that, when they are prescribed, they are often associated with other drugs. In a way, oral rehydration is therefore a paradox. How can we explain that a real gap exists between medical advice whose validity is acknowledged by the practitioners themselves and what these same physicians prescribe? The assumption on which this study was based is that this discrepancy is not basically due to a lack of information, as most physicians and families who were interviewed knew about ORS and the dangers of diarrhea. This gap would be due mostly to the fact that oral rehydration does not meet the expectations of the families who bring in their children. In other words, it would result from the lack of communication between the medical approach and that of the family. To verify this assumption, six ethnologists and sociologists have carried out a comparative and qualitative anthropological survey in five locations: Oran (Algeria) and Bangkok (Thailand) for the two in-depth studies and Cairo (Egypt) and Beijing and Urumqui (China) for the two exploratory studies (3). The following criteria for the selection of sites were adopted: diverse cultural backgrounds in the fields of therapeutics (Oriental and Arabo-Moslem cultures), urban neighborhoods in which diarrhea was frequent, and finally, clinics and hospitals at which ORS were to be prescribed (except in the case of China, where the selection of neighborhoods and clinics could be done only via an information social network). To be thoroughly informed of the real approaches and proceedings adopted by families and physicians, in-depth interviews lasting from 1 to 3 h were conducted at the worksite or in the home. Health care and diagnosis practices were observed for a half-day, where decisions were taken by families or physicians (neighborhood, house, clinic, pharmacy). The content was analyzed theme by theme following the itinerary method, indicating step by step the moments where decisions are made and the factors having an impact on these decision. Discussions took place in French, Chinese, Arabic, and English, with the help of bilingual interpreters and ethnologists (French-Arabic, English-Arabic and French-Thai). The results took the form of notes written during or after the interviews, descriptions of written observations, and photographs of the environment. The survey focused on familial self-medication practices, traditional health care, or use of biomedicine. Concerning the latter, it included the use of ORS recommended by the WHO and the diversity of therapeutic methods prescribed by physicians in their private or public practice. Criteria for the selection of observations and interviewed subjects were as follows: families were selected in the clinics at the time the child was brought in; they were asked if they agreed to receive the survey personnel in their own homes, in their neighborhoods. At least one major diarrheic episode must have occurred in the family within the last 12 months. The physicians who were selected for the study were all pediatricians, in both public and private practice, having a good knowledge of ORS, whether or not they prescribed them. The pharmacists included in the study had to sell antidiarrheic drugs, either biomedical or traditional medicines. The average number of cases observed per site included 25 families with children between 0 and 2 years, 10 physicians, and 8 pharmacists. When looking at morbidity manifestations and health care as seen by families, three main items were observed. Diarrhea was not always considered by the families as a disease. It is even considered as a normal feature of child development (in Egypt and China) or as a positive sign: especially as an indication that passage to the sitting, then the standing position took place normally (in Thailand).When diarrhea was perceived as a disease, it was most often considered a simple benign disease.In all societies, however, a difference was made between benign and serious diarrheic episodes.Each culture group, even each family, had established its own scale regarding the gravity of a disease. This scale varied, which explains why some families consulted a physician when the child presented with the first manifestations and others after 2 weeks of diarrhea.The signs of a serious episode, however, were generally associated with an increased number of stools, some alarming changes in the child's behavior (crying, weakness, refusing to eat), and the occurrence of new signs such as blood in the stools.In all cultural backgrounds, diarrhea was never considered a serious dramatic event, contrary to what happens with AIDS in Europe, for instance. It is seen as a “down-to-earth disease.” Because this disease is most often considered as banal, the designers of public health campaigns have been led to dramatize the real danger of diarrhea. This type of information sensitizes the families, but it also creates more expectations regarding therapy. In particular, families expect to receive some kind of prestigious drug, with a fancy packaging or a high price. Above all, they expect that diarrhea will stop immediately, and the therapeutic management will have to take these expectations into account. When looking at family's therapeutic approach and medical prescriptions, four items were noted. Observations and interviews emphasized the great diversity of the therapeutic approaches: families could decide alternately to come to the hospital or the clinic, to use traditional medicines or visit a private practitioner (except in China where there is no biomedical private medicine) or a pharmacist. To provide health care, the physicians were therefore in a competitive situation. In the case of diarrhea, patients did not perceive easily that dehydration had stopped because it escaped the eye.Families could observe the disappearance of the signs of diarrhea that were readily visible: no more liquid stools, no more cries from the child, no more blood, etc.Physicians could not ascertain their diagnosis. Without laboratory tests, they could not know for sure if the diarrhea had a bacterial or a viral origin, but these tests were not always possible because of their cost or due to a great geographic distance. Observation and detailed knowledge of the adopted practices indicated that private physicians, and even those in the public sector, would base their biomedical treatment of diarrhea on the prescription of five or six drugs: antidiarrheic, antiemetic, and antipyretic agents, often associated with antibiotics and sometimes ORS. Finally, in terms of practices and family opinions regarding ORS, two items were noted. The observation in the family environment of oral rehydration practices showed that the families did not follow easily the rules established in the prescription. It was often noted that the packet of salt was poured into the baby's bottle all at one time, and not given teaspoon by teaspoon for a longer period. ORS had a negative image, because they are not efficient, according to some families. The mother (or in Algeria, the mother-in-law) did not see the end of the diarrhea. ORS did not appear to be serious enough to counter the dangers announced in the information campaigns. Thus, the survey on medical practices carried out in the four countries confirmed the gap between the advice given by the WHO and what was really prescribed. This survey also showed that approaches of families and practitioners did not converge. It focused on the following paradox: the efficacy and scientific validity of a drug, its easy and simple preparation, and its low cost may be contrary to its widespread distribution as a therapeutic agent. Accordingly, to ascertain that oral rehydration will be used by families, a sociological analysis has shown that five conditions must be met but that only one is really satisfied. A scientific condition: oral rehydration must prove its efficacy; this is the only requirement that has been met (4). A cultural condition: families must consider diarrhea as a disease, but this is not always the case. A semiologic condition: the manifestations of the efficacy of the treatment must be easily recognized by the child's family, but ORS does not stop the signs of diarrhea. A strategic condition: a treatment must not represent a threat to the physician's expertise, but ORS is one (5,6). An information-related condition: in the communication process no contradiction must appear between the dramatic image given of the disease and the banality of the treatment; but the ORS packaging is not seen as serious by the families and this goes against the prestige of the physician. In conclusion, to encourage adopting an oral treatment of diarrheic episodes, it is necessary to take into account better the constraints imposed on physicians and their prescriptions in their daily practice and those related to the success of their professional career; it may also depend on the development of a drug that, in association with ORS, could stop the manifestations of diarrhea without the disadvantages of usual biomedical treatments prescribed to children <2 years of age. Dominique Desjeux; Isabelle Favre; Joëlle Simongiovanni; Laurence Varge; Marie-Hélène Caillol; Sophie Taponnier Department of Social Anthropology Paris V-Sorbonne and Argonautes Paris, France Jehan Francois Desjeux Inserm U290 Hopital Saint-Lazare 75010 Paris, France