ABQJOURNAL HEALTH: Diarrhea deaths reduced

Monday, June 08, 2009

Diarrhea deaths reduced

By Lance Chilton
For the Journal
          It's just 50 years since the Indian Sanitation Facilities Construction Act was passed by the U.S. Congress. The act gave the Indian Health Service, then just 4 years old, the task of improving hygiene on the nation's reservations.
        Eleven years later, when I arrived at work in Gallup, most of my patients were still hauling water from distant springs and indoor plumbing was an unheard-of luxury. I became adept at "cutting down" on Native American children — they were so dehydrated from diarrheal illness when they got to the hospital, it was impossible to find a surface vein into which to run lifesaving intravenous fluid, and we had to cut into the skin to put a tube directly into a vein.
        The sanitary engineers of the Indian Health Service have continued to work ever since bringing sanitary facilities to reservations throughout the West. If you look at a graph of the proportion of Native American homes having indoor water supplies superimposed on a graph of deaths due to diarrhea, you'll find a perfect "X"; as the number of families using available clean, safe water has climbed, the incidence of death due to intestinal disease in childhood has fallen, now to about one-fifth the rate I saw when I arrived in Gallup.
        Of course, other things have changed as well: For example, pavement has allowed reservation families to travel to get help much sooner than in 1970, and stores on "the Rez" now sell fluids that can be used to rehydrate the body. Doctors, especially in parts of the world where diarrhea is more common and more deadly, like Bangladesh, recognize that oral rehydration will save the large majority of those sick with even severe diarrhea.
        None of this diminishes the importance of sanitation in preventing disease, especially diarrheal disease. We suffer from far less disease of the intestines than our neighbors south of the border, where water supplies are chronically contaminated. While Americans have relatively few problems with bacterial causes of diarrhea, Mexican children frequently are infected with bacteria, as well as parasites.
        You may have noticed that I have said nothing about antibiotics so far. Especially in the U.S., antibiotics and other medicines have little role to play in treating diarrhea. At this time of year, I have several patients each day whose care consists almost solely in making sure they get enough to drink. Several times a day I find myself telling parents that they're doing a good job keeping their children "well-watered," and that they need to keep giving fluids, even if a child with diarrhea and vomiting doesn't seem to "be able to keep anything down."
        Summer diarrhea is not usually severe in this country. The viruses that cause those frequent intestinal infections seem to burn themselves out in just a few days, and few children are sick enough to need hospitalization. Children shouldn't use anti-diarrheal medicine — most of it is ineffective and can occasionally be dangerous.
        Over the past several years, we have seen less of a severe winter diarrhea caused by a germ called rotavirus. The reason is that an effective, safe vaccine was introduced several years ago and is given to most infants in their first eight months. Rotavirus causes a large proportion of the hospitalizations for diarrhea each year, but we're hoping that it will become as rare as diphtheria or polio.
        Most of you have read of another source of diarrheal disease: contaminated food. The tomato scare that turned into a jalapeño scare was one example of a disease caused by contamination with a bacterium called salmonella. This past year, salmonella was brought to us courtesy of the Peanut Company of America. Experts indicate that these episodes are not at all uncommon, made more dangerous and more widespread by the globalization of our food supply. We would probably be better off to go back to growing our own food.
        We would not be better off, however, to go back to a world without sanitation or without the epidemiologists who can chase down the cause of diseases like diarrhea. The epidemiologists can find the causative microbes; the sanitary engineers can find ways to prevent their depredations. Congratulations to the Indian Health Service on its first half century of bringing disease-free life to our first Americans!
        Lance Chilton, M.D., is a pediatrician at the Young Children's Health Center in Albuquerque, associated with the University of New Mexico. He is happy to take questions at 272-9242 or lancekathy@yahoo.com.

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