A reappraisal of how oral rehydration therapy affected mortality in Egypt

Oral rehydration therapy is the key low-cost child survival intervention used to deal with diarrheal illness in developing countries. The existence of a low-cost, highly efficacious technological fix (oral rehydration salts) for the life-threatening dehydration that accompanies diarrhea provided a strong rationale for making oral rehydration therapy a cornerstone of diarrheal disease control programs. The Egyptian oral rehydration therapy program has been quoted as having the most spectacular success in reducing infant and child mortality. But there is a need to differentiate between the efficacy of oral rehydration therapy in clinical settings and in community use. The National Control of Diarrheal Diseases Project (NCDDP) was launched in Egypt in 1983. A pilot program was followed by national promotion starting in February 1984. As early as 1985, opinions were being expressed about the favorable impact of NCDDP activities on child mortality. There is no doubt that the NCDDP greatly increased both awareness of the dangers of dehydration consequent upon diarrhea in children and knowledge of oral rehydration therapy. But survey data on the use of oral rehydration therapy during diarrheal episodes show such use to be far from universal (with use in fewer than 50 percent of episodes). Futher, ethnographic studies show appropriate use, in terms of timing and quantity, to be the exception rather than the rule. The maximum theoretical effect of the NCDDP on child mortality would be to eliminate all deaths from diarrhea, a reduction of about 50 percent. The maximum effect that could realistically be expected is a reduction of less than 20 percent. Analysis of a time series of infant mortality from vital registration data indicates an abrupt, statistically-significant change in level in 1985 amounting to a once-off decline of about 15 percent. In the absence of other changes taking place at about the right time that might explain this drop, it is concluded that the NCDDP probably was responsible. Thus, although many of the claims made for the impact of the NCDDP on child mortality in Egypt appear to have been greatly exaggerated, it does seem likely, in the absence of alternative explanations, that the program significantly reduced infant mortality in the mid-1980s.