The soap story #PetPeeveStories

“There is no greater fool than the fool that was fooled by a fool.”

And nothing sets that example better than those very bad, false advertisements you see on media.

Let me tell you about a true story. It’s the story of a soap.

Atul Gawande, one of my favorite authors, wrote in his book entitled “The Checklist Manifesto: How to get things right” as reference for this story.

One of the most revealing public health studies published was a joint public health program conducted by the US CDC (Center for Disease Control) and HOPE, a charitable organization in Pakistan, “to address the perilous rise of premature deaths among children in the slums of Karachi. The squatter settlements surrounding the megacity contained more than four million people living under some of the most crowded and squalid conditions in the world. Sewage ran in the streets. Chronic poverty and food shortages left 30-40% of the children malnourished. Virtually all drinking water sources were contaminated. One child in ten died before age five – usually from diarrhea or acute respiratory infections.

The roots of these problems were deep and multifactorial. Besides inadequate water and sewage system, illiteracy played a part, hampering the spread of basic health knowledge. Corruption, political instability, and bureaucracy discouraged investment in local industry that might provide jobs and money for families to improve their conditions. Low global agriculture prices made rural farming impossible, causing hundreds of thousands to flock to the cities in search of work, which only increased the crowding. Under these circumstances, it seemed unlikely that any meaningful improvement in the health of children could be made without a top-to-bottom reinvention of government and society.

But a young public health worker had an idea. Stephen Luby had grown up in Omaha, Nebraska, where his father chaired the obstetrics and gynaecology faculty at Creighton University. He attended medical school at the University of Texas Southwestern. But for some reason he was always drawn up to public health work. He took a CDC job investigating infectious outbreaks in South Carolina, but when a position came open in the CDC’s Pakistan Office he jumped to take it. He arrived in Karachi with his schoolteacher wife and began publishing his first investigations of conditions there in the late nineties.

When Gawande had spoken to him about how he thought through the difficulties, Luby looked for low-tech solutions. In this case, the solution he came up with was so humble it seemed laughable. It was soap.

Luby learned that Procter & Gamble, the consumer product conglomerate, was eager to prove the value of its new antibacterial Safeguard soap. So despite his colleagues’ skepticism, he persuaded the company to provide a grant for a proper study and to supply cases of Safeguard both with and without triclocarban, an antibacterial agent. Once a week, field workers from HOPE fanned out through 25 randomly chosen neighborhoods in the Karachi slums distributing soap, some with the antibacterial agent and some without. They encouraged people to use it in six situations: to wash their bodies once daily and to wash their hand every time they defecated, wiped an infant, or were about to eat, prepare food, or feed it to others. The field-workers then collected information on illness rates among children in the test neighbourhoods, as well as on 11 control neighborhoods, where no soap was distributed.

Luby and his team reported their results in a landmark paper published in Lancet in 2005.

What did the interventional study reveal?

1. Families in the test neighborhoods received an average of 3-4 bars of soap per week for one year. The incidence of diarrhea among children in these neighborhoods dropped 52% versus the control group, no matter which soap was used.

2. The incidence of pneumonia fell 48%.

3. The incidence of bacterial skin infection (impetigo) fell 35%.

These astounding results were achieved despite the illiteracy, the poverty, the crowding, and even the fact that, however, much soap they used, people were still drinking and washing with contaminated water!

According to Luby, Procter & Gamble were disappointed with the outcome of the study because the research concluded what infectious diseases specialists knew all along – there was no added benefit with the antibacterial agent because plain soap was just as effective.

Soap and proper hand washing was enough leverage to change the landscape of infectious diseases in the community.

And several studies before and after this landmark study had shown that proper hygiene was all that mattered.

No advertisement. No fooling the public on what soap to buy. None of that bullsh*t endorsement at all.

I tell this story to my friends and patients so that it serves as a firm reminder that NOT all marketing strategies are truthful. I’ve always told my students that a good product or commodity or drug will sell on its own. The rest need the power of push – exaggerated advertising claims!

In this dog eat dog world, let’s put a little sense into common sense and not depend on the crap that endorsers day. After all, they get paid millions of pesos to make a fool believe the fool.

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