August 17th, 1968. The British Journal Lancet publishes a study conducted in what was then East Pakistan. A team of American doctors, working closely with local clinicians cracks an age-old problem that affects millions around the world. It shows that a simple oral rehydration solution (later known as ORS or ORT, with T for therapy) can save lives of those who would have otherwise died from cholera. The simple solution, given orally, contained glucose and electrolytes. The study pioneered by two American doctors, David Nalin and Richard Cash, would change public health forever. A 2007 study showed that ORT has saved the lives of at least 54 million people, many of whom are in our part of world, who would have otherwise died from diarrheal diseases.
The story starts in Dhaka in August 1967. David and Richard landed in the city for the first time within weeks of each other. It was a set of circumstances, the revulsion against the Vietnam War and a commitment to do good public health research that got them to a bustling city in East Pakistan. Both, whom I spoke to in the last few months, have very fond memories of the time. “It was very safe, you didn’t have to lock your doors,” recalls Richard. David also felt comfortable and was fascinated by the culture, smells, sights and sounds. Neither of them saw any communal tensions that were to grip the region a few years later.
Neither David nor Richard had been trained as cholera experts, but with cholera striking year after year, this was a problem that was impacting families, communities and society as a whole. If you wanted to change lives, this was the problem to solve. People would waste away, in a matter of days, and die a painful death. Familiar with the research up until that point, including previous failures, David and Richard knew that hydration was the key. Electrolyte importance had also been established. There was also evidence showing the importance of glucose. The science was there — in pieces, close enough but still elusive. It was time to put the pieces of the puzzle together.
The main challenge was not just what to give the patients but also how. They came up with an oral rehydration mechanism, recognising the importance of electrolyte replenishment and started a risky trial at Cholera Research Labs in Dhaka. Both David and Richard remember the events vividly and shared them with me in crisp detail. Over the next few days Richard and David were on call 24 hours a day. The trial began in April of 1968. All 29 patients who were given the oral rehydration therapy recovered in a matter of two days. The results were a resounding success. Lancet published it 50 years ago this month. Subsequent trials with younger patients and in rural areas further established ORT as a potent life saver. Sir Fazle Hasan Abed, a Bangladeshi social worker par excellence, made ORT even more accessible to rural women. The solution became a simple chant — a pinch of salt, a fistful of sugar and half seer of water. It was the simplicity of innovation, resting of strong science that made it possible for vulnerable babies to survive.
David and Richard wrote a piece reflecting on their legacy in Lancet last week. They point out four key lessons as guiding principles. These include strong scientific evidence needed for innovation and therapeutic intervention. Second, doing research in the field and areas that are the epicentre of the problem is critical. Third, there are field trials and international support to generate across the board evidence and finally continuing on the path to innovate.
We owe a lot to David, Richard and those who have helped save the lives of our loved ones — but not just for their work on ORT but also on teaching us how to create public health miracles.
Published in The Express Tribune, August 21st, 2018.