Simple Oral Therapy Helps Third World in Fight Against Diarrhea
For the children of the world, hope springs from the strangest places.
For instance, this market town up the hyacinth-choked Dhona Goda River, situated amid steamy green rice paddies.
It doesn’t seem like much: a row of open-front market stalls, huts of dried mud, a few brick buildings, hungry-looking rickshaw peddlers waiting at the bank.
But this isolated hamlet 35 miles from Dhaka, Bangladesh’s capital, has a place of honor in the annals of public health. Here, a seminal payoff was coaxed from what the Lancet, Britain’s medical journal, termed “potentially the most important medical advance this century.”
“It has been an amazing success if you measure it in terms of lives saved,” said Dr. Richard Cash of the Harvard School of Public Health in Cambridge, Mass.
Cash is referring to a revolutionary technique called Oral Rehydration Therapy. Thanks to ORT, parents from rural Bangladesh to Botswana and Bolivia can nurse their children out of most bouts of diarrhea themselves, with a medicine no harder to make or take than Kool-Aid.
UNICEF, the United Nations Children’s Fund, estimates that 1 million young lives are being saved annually. And diarrheal diseases have been driven down UNICEF’s list of global child killers, from first place to third.
Cash, as a rookie U.S. Public Health Service officer, played a key role in the pioneering work here. More than a quarter-century ago, in this cholera-prone area of South Asia, where up to 40% of victims died, a small number of doctors, including Cash and another young American, embarked on the field test of a new treatment.
Their target was the diarrhea caused by cholera--which dangerously dehydrates the body and leaches it of essential salts.
This messy, unpleasant health problem is one some prefer not to mention. But the World Health Organization estimates that over the past 40 years, no fewer than 150 million people have died of dehydration by diarrhea--more than the dead of both world wars.
In what is now the country of Bangladesh, physicians building on past research and clinical trials perfected a treatment that turned the old orthodoxy on its ear. The therapy’s experimental foundations and the first cautious attempts at practical use are so complex (and jealously contested) that they take up 34 pages in a recent journal of medical history. But one undisputed major player was Dr. Robert A. Phillips, a retired U.S. Navy captain whose research into cholera won him the coveted Albert Lasker Clinical Science Award in 1967.
Cholera victims used to be routinely rehydrated with intravenous infusions of saline--a treatment too costly and sophisticated for most of the developing world. But in 1962, when an epidemic broke out in the Philippines, Phillips discovered that patients who drank a “cholera cocktail”--glucose added to a solution of sodium, potassium and bicarbonate--could absorb a lot more of the electrolytic salts through their intestinal walls.
When Phillips attempted a large-scale trial, however, five of the 30 subjects died.
The story then shifts to a cholera research laboratory in Dhaka founded in 1960 by the United States, Pakistan and the Southeast Asia Treaty Organization when Bangladesh was part of Pakistan. Phillips was named to head the lab but, say co-workers today, seemed to have gotten cold feet about continuing Oral Rehydration Therapy research.
Cash, then 26, arrived in Dhaka in 1967. About the same time, Dr. David Nalin, the same age and with one year of medical residency, was shipped off to the Dhaka lab by the National Institutes of Health. Both men became determined to push the edge of the envelope on ORT.
One clinical test in the southern Chittagong district was not encouraging, while a second at the Dhaka lab’s hospital was. The innovation he and Nalin were pursuing, Cash explained in a recent interview, was to precisely coordinate oral fluid intake with fluid loss from diarrhea and vomiting, and to use IVs as little as possible.
The Americans decided they needed a field test in the rugged conditions common to the Third World to prove ORT could work in “real life.” The lab’s field station at Matlab was selected.
The town had no electricity then, and available medical technology was dauntingly basic: thermometers, a blood pressure cuff, stethoscopes, a scale and a kerosene-fired incubator for growing viral cultures. The doctors and their Bangladeshi colleagues had to sleep aboard a houseboat that was once a jail. Ashore, the patients, drained by diarrhea, languished on “cholera cots”--narrow bed boards with a hole cut in the middle and pails positioned underneath.
One hundred fifty people were rehydrated and re-mineralized with the oral solution, and not a single one died, Cash said. The 1968 Matlab trial decisively proved the “cholera cocktail” was safe and practical, could be used to treat large numbers and eliminated the need for large amounts of IV fluids.
In Calcutta, there soon followed a hasty and dramatically successful application of ORT to thousands of cholera-infected refugees from the 1971 Bangladeshi war of independence. The therapy also proved effective against other pathogens that cause watery diarrhea and worked in children as well as adults.
The Dhaka lab was reorganized in 1979, becoming the International Center for Diarrheal Disease Research. In April, it was visited by First Lady Hillary Rodham Clinton, who has taken a keen interest in women’s and children’s health.
But ORT’s story is not all triumph. “If you measure things by the number of kids who take it, then it’s a modest success,” said Cash. UNICEF’s goal is to make prepackaged oral rehydration salts available to 80% of the world’s children by year’s end. That’s clearly not going to happen.
“We have not even gone halfway,” said Dr. Stephen J. Atwood, chief of the health section at UNICEF in India. “The usage rates are still around 25% to 30%.”
Worldwide, a full quarter of deaths of children younger than 5 are still blamed on diarrhea. Even in Bangladesh, more than a quarter of a million children will die of it this year, the Ministry of Health estimates.
