Primeros Pasos is a clinic that charges $0.62 cents for a pediatric consultation and $3.75 for an adult to see a provider. Any medicine in the pharmacy is free with the cost of admission and some remedial laboratory work is included in the nominal fee as well. The clinic is constantly receiving miscellaneous grants and substantial financial support from Inter-American Health Alliance (IAHA) to pay the salaries of the few employees that run the place and then volunteers take care of the rest. Lauren and I noticed two issues at the clinic that we felt we could address to cut costs and improve patient care. She moved directly into improving malnutrition treatment protocol and wrote an entire study that is waiting approval. We also have found that the clinic is frequently without oral rehydration salts (ORS) used as treatment for people, but especially children, with diarrhea. Lauren and I were frustrated by the absence of ORS packets in the pharmacy, which led us to create a project to expand care at Primeros Pasos. Finding the perfect recipe for ORS and buying 100 pound bags of salt and sugar is our immediate goal.
Severe diarrhea causes extensive loses of fluid and electrolytes and a child's body does not have the reserves to compensate for missing essentials. Before ORS (known as suero in Spanish) was instituted, intravenous fluids were used to correct diarrheal dehydration and millions of children were dying because they didn't have access to technical medical care. Now we can remedy the situation with salt, sugar and clean water. Rehydrate.org quotes that ORS therapy saves 1 million lives a year, costs about 10 cents per liter of solution and can prevent about 90% of diarrheal deaths in children. The initial recipe for ORS included 8 teaspoons of simple sugar, 1/2 teaspoon of table salt and one liter of pure water. Through many research studies and trial and error efforts, the recipe has been refined and enhanced to optimize diarrheal treatment for the vulnerable, yet resilient bodies of children. There are websites suggesting that vitamin C and zinc can be used to diminish the length and severity of diarrhea by up to 25%. Other sources have been adding artificial flavorings and additives to make ORS more palatable, but in our search for the best recipe we have chosen to abide by the most trusted and overarching source of pediatric medical care. The World Health Organization and UNICEF have combined to create a 123 page manual about oral rehydration therapy and this is now our guiding light. The WHO and UNICEF offer a simple recipe of 2.6 grams of salt, 1.5 grams of potassium chloride, 2.9 grams of trisodium citrate dihydrate and 13.5 grams of glucose. Four ingredients with life saving potential, all of which are usually available at any nearby grocery store.
The two ingredients that are rather abnormal for a grocery store are the trisodium citrate and potassium chloride, but thankfully there is research suggesting that baking soda can be substituted for the trisodium compound. Trisodium serves as a buffer for the acidosis of severe diarrhea and thus baking soda can serve the same purpose. Potassium being the second issue was not a worry because in the United States we prescribe large quantities of potassium chloride to patients on diuretic therapy and potassium chloride can also be bought as a salt substitute in most stores. Furthermore, I can walk into any pharmacy in Xela and buy almost any medicine I desire, except of course potassium chloride. I felt very few qualms about finding a source of potassium, but I should have realized that the recipe wouldn't be so easy to complete. Potassium chloride seems to be non-existent in Guatemala after a long and thorough search throughout the medical and scientific community.
We started this project with the idea of having four ingredients locally available and we would then have an suero recipe working at the clinic within a week, but the obstacles to our creative alternatives are becoming all too common. These barriers we have found are very frustrating because it is yet another reflection of the restricted resources in comparison to what is at our medically oriented finger tips at home. We have visited a half dozen pharmacies, called local laboratories, considered having volunteers bring prescription potassium from the states, but all proved to be without potassium chloride or expensive, unsustainable and hapless. Lacking a reliable source of potassium chloride has forced us to be inventive in our search for this electrolyte and our team has been delving through research studies as we attempt to compensate for the missing ingredient. Due to the importance of potassium, we want to include as much of it as possible even if we cannot add the 1.5 grams stated in the WHO/UNICEF recipe.
There is a unadulterated, unprocessed sugar in Guatemala called panela or piloncillo and it is apparently loaded with potassium and could be perfectly useful, if we only knew how much potassium there is in every gram. Panela is a locally grown, produced and useful ingredient for the ORS suero recipe, which would keep cost down, make the recipe useful for other clinics in the area and be a culturally sound contribution to the medical efforts in Xela. And knowing that the original life-saving recipe lacked any form of potassium, we are confident that the increased amount found in panela will be very beneficial as long as we keep the osmolarity balanced. Along with the potassium in panela, we can also include potassium iodized salt as another minimal, but useful source of the vital electrolyte.
We still need to standardize and exact the recipe, but thankfully we have a Phd trained chemist back in Nashville to calculate the exact osmolarity (number of solutes per liter of water) to ensure that the amount of additives we are using will be perfectly therapeutic and beneficial for patients with diarrhea. The osmolarity must be kept below 245 per liter of pure water to avoid dehydrating the body further and the chemist will be able to give us the weighted measurements for a safe recipe including sugar, salt, panela and baking soda. We shall continue to seek the answers to our long list of questions and we hope that this research experiment will soon produce necessary results to cut costs and increase the availability of oral rehydration therapy at the Primeros Pasos clinic in Palajunoj Valley, Guatemala.