See Transcript
{***Pause/Music***}
{***Noah***}
Coming up on Harvard Chan: This Week in Health…
The story behind one of public health’s greatest success stories.
{***Richard Cash Soundbite***}
Oral Rehydration Therapy is credited with preventing tens of millions of deaths from cholera and other diarrheal diseases. In this week’s episode you’ll hear from two of the scientists who helped bring this low-tech, inexpensive treatment into worldwide use.
{***Pause/Music***}
{***Noah***}
Hello and welcome to Harvard Chan: This Week in Health. I’m Noah Leavitt.
It’s a simple solution: water, sugar, and salt. But Oral Rehydration Solution—or ORS—which is administered as part of Oral Rehydration Therapy—or ORT—is credited with saving tens of millions of lives from cholera and a range of other diarrheal diseases.
To put the impact of ORT in perspective consider that 500-thousand people each year—half of them children—die from diarrhea worldwide. That’s a huge number. But the number of deaths from diarrhea has actually fallen by 80% since 1980 because of ORT.
Fifty years ago, scientists began the first clinical trials to assess the effectiveness of ORT. Those studies helped catapult this low-cost but effective treatment into worldwide usage.
A recent event hosted by the Harvard Global Health Institute honored one of those scientists, Richard Cash, a senior lecturer on global health at the Harvard Chan School. Cash, along with David Nalin, conducted clinical studies with cholera patients in Dacca, Pakistan—now Dhaka, Bangladesh—in the late 1960s at the Cholera Research Laboratory, showing that the water-sugar-salt solution was remarkably effective in reversing dehydration. ORT’s effectiveness was demonstrated on a much larger scale in 1971, during the India-Pakistan War, when it was successfully used to treat large numbers of refugees.
At the time, the ORT seemed almost deceptively simple. Before the introduction of ORT, the standard of care was to treat diarrhea with intravenous fluids—which can be expensive, dangerous, and often isn’t even available in low-resource settings. But ORT was cost-effective and importantly accessible—health care workers could easily train people to make the solution on their own for use on family members simply by using a pinch of salt, a fistful of sugar, and half a liter of water.
So how did this simple treatment spread worldwide?
In this week’s episode we’re sharing a fascinating conversation between Richard Cash, David Nalin, and Stefanie Friedhoff, the Assistant Director of Communications at the Harvard Global Health Institute.
They spoke about the development of ORT, the process of proving its effectiveness, and the lessons that can be learned from ORT. A key theme you’ll hear throughout the conversation: ORT likely wouldn’t have happened without working closely with doctors and health care workers working on the ground in Bangladesh and elsewhere.
David Nalin began the conversation by explaining that the solution itself was really only part of the therapy. A key step was teaching doctors and even parents to recognize the signs of dehydration in children or family members early enough that ORS could be used.
{***Richard Cash and David Nalin Interview***}
DAVID NALIN: So it’s not one thing. It’s a solution, a method, and a change from the old dietary practices.
RICHARD CASH: And let me reinforce that the first step of this, which is we first became involved with, was testing out the solution itself, which was called ORS. Oral re-hydration solution. Once that was shown to be effective and could be effectively absorbed, it was added to the dietary strategy, which was already in use at the hospital that we were at and the research center. And then extending it beyond the hospital and the clinic to the community.
DAVID NALIN: I would like to point out that although we commonly call it oral re-hydration therapy, the ultimate goal is oral maintenance therapy. That is giving the oral solution to the child. Giving the oral social by its mother at the start of diarrhea to prevent dehydration, and shock, and death. Of course, most cases are mild. There, the oral maintenance before the child is dehydrated serves to avoid inappropriate and harmful therapies, unnecessary intravenous therapy, and unnecessary admissions. And to teach the mother how to mix it and give it so that she knows that next time if another child gets more severe diarrhea what to do.
So oral therapy has positive benefits and negative benefits. It eliminates a lot of inappropriate therapy. And it gives a chance to maintain fluid balance and prevent dehydration.
STEPHANIE FRIEDHOFF: Let’s take a step back for a moment. I read up a little bit and found that the idea of putting sugar, and salt, and water together had been experimented with since the 1940s?
DAVID NALIN: Well, this is a question of translational medicine methodology. In fact, if you go back to Galen, the old books say he could be the father of oral therapy because he recommended broths. Both farinaceous broths, rice broth, which we use today. Chicken broth. But they leave out certain things. They pick that part. And they don’t mention that he recommended along with that, diarrhea patients should be treated with oysters.
So we’re talking about magical medicine. There’s no method. There’s no intake and output. There’s no relationship of clinical signs of dehydration to the outcome. So a lot of this is in methodology. Now, of course, since oral therapy became popular, we find many people saying that oh yes, so-and-so gave it then. So-and-so gave it then. And I’ve looked into this extensively. And it’s true. I was the first to rediscover it– I think. And it was put into a textbook that a Bengali doctor, Chatterjee, he claimed he published in The Lancet– and I guess it was ’53– that he had treated a series of cholera patients. Proven cholera– bacterial logically proven– with an oral glucose and saline solution.
And people have since then gone back and say, oh, look they ignored him. Maybe it was colonial racism or something. But if you look at his article, he gave it rectally as well as orally. He gave it with avomine as an antiemedic. He gave it with a mixture of coleus aromaticus, which was a folk treatment for stopping diarrhea, which happens to be the main source of forskolin. A compound which raises cyclic AMP. And is believed to cause fluid secretion.
Also, he only gave it to the mild cases who had a good pulse. I think it was about 150 out of 1100 patients. The others got IV. And so there’s a whole mix of things.
RICHARD CASH: I want to emphasize with what David is saying here is that a lot of it was based on not science but what I call faith based medicine. That is it seemed like a good thing to do. But there was no clear scientific study that showed that it worked, what the correct formulas should be, and most importantly, what is the method of giving it.
So there is a method. There is a strategy for giving it. And a lot of these early studies were given small amounts as the person was almost fully recovered. So it wasn’t a strategy to maintain hydration or to rehydrate. But rather it was not based on evidence. It was based on a belief system.
STEPHANIE FRIEDHOFF: So this is a very important point. If we think about global health’s practice. You didn’t just talk a solution that maybe had been described before. You also described a protocol, developed a method, and developed the tools to actually measure [INAUDIBLE].
RICHARD CASH: But you raise a good point. The things build on each other. And so there are physiologic studies testing out different solutions, and different substrates, and so on. Because you always stand on the shoulders of those who come before you. There’s no scientific-
STEPHANIE FRIEDHOFF: My question is actually at the time, what were your influences? How and why did you set it up the way you did?
RICHARD CASH: Well, at the time when people had always in the part of the world where cholera was prevalent, which was in Bengal, [INAUDIBLE], and so on, there was a tremendous shortage of health providers. So they knew that IV therapy worked. But there was one doctor for every 50,000 people. There was no nurses. There was no IV. There were no needles. No tubing.
And so it was clear that if you were going to get therapy to where people were– and transport you didn’t hop on the bus, you came by country boat– you had to develop something that could be used where the people were. And that meant you had to probably use an oral solution. So that drove people to think how can we get something that we can actually take out there? And there wasn’t very much intravenous fluid. We made up our own at the institution that we were at.
So there were two objectives there. One, could we save the amount of IV fluid that we actually needed? Could we reduce the amount? And secondly, could we actually get it out to where there was no fluid? And maybe even start something earlier. And clearly, it was the oral route that had to be exploited.
DAVID NALIN: What got us to that point was we were embedded in the local [INAUDIBLE] where the [INAUDIBLE] population was. And that gets back to what I was telling you. No cholera in Dhaka. How are we going to do research? So we got a call from the Christian Memorial Hospital in Cox’s Bazar. Then 80 miles of pristine beach. And now, filled with a million Rohingya refugees from Burmese genocide.
And we go down to this remote area. And there’s this beautiful Christian Memorial Hospital, still functioning after all these years by the way, serving local community. And it’s empty. They call us for cholera outbreak [INAUDIBLE] because the local mullahs told the Muslim population if you go to the Christian Hospital, they will brand your forehead with the sign of the pig. Haram forbidden in Islam.
They were afraid that if they got [INAUDIBLE] benefits, some of them might convert. So here were patients dying in the villages-
RICHARD CASH: People knew they were dying in the community.
DAVID NALIN: Because their families that would rather have them die at home than in the Christian Hospital. In a way, it reminded me of at that time from fresh out of this residency of the families of terminal cancer patients in the US. Let them die at home rather than the hospital. It’s hopeless. They all die.
Their thinking was cholera is invariably fatal. And we don’t want to get pig branded. Let them die in the hut. So we went to see what was going on in these huts. And one of the villages I remember was [? Turinga, ?] which was built around a paved air strip relic of World War II of the Flying Tigers who used it to fly sorties into occupied territory occupied by Japan in Burma and back.
And they had built the village around this because it was good for threshing rice. And we went inside one of the huts, and it was dark. And I could see this nine-year-old girl, Amina Katoon, I still remember her name. And her eyes were totally sunken. Her pulse was feeble. She couldn’t hardly talk. And her father was trying to warm her shriveled fingers with a pot of coals. She was on the verge of death.
Well, I was fortunately with one of our colleagues, the late doctor, [INAUDIBLE] Huck, who spoke Chittagonian dialect completely different from standard Bengali. And he argued and argued with the father to let us at least if we couldn’t take her to hospital, let us give her an IV drip in the hut. And he finally agreed. Reluctantly he agreed. And we gave the IV drip. And in a few minutes, her eyes filled up. Her voice came back. She began thrashing around and yelling out punny, which means water. She was thirsty.
And seeing this he was astonished. And so were the other onlookers. In fact, so many people had gathered to see what we were doing at the entrance of the hut, and [INAUDIBLE] Huck had to turn around. And I’ll never forget this. And he said, what are you looking at? Don’t you know this is cholera? And when they heard the cholera word, they ran. And that gave us permission to take her to the hospital where she recovered. And after hearing this, the villagers flooded the hospital. And we could start our research.
RICHARD CASH: I want to go back to what David was suggesting. Is that being embedded in the place, see what facilities you had, what resources you had, and so on, increasingly educates you as to what you can do and what you can’t do. You can’t do certain things because you don’t have the resources.
It can’t be a doctor induced approach because there are no doctors and so on. So you’re constantly looking at ways as to how can we get this down to its basics? And to simplify something is not as easy as complicating. Complicating is easy. But to strip away and say what do we really need here, which happened after we demonstrated that it worked and that people would be in balance in terms of their electrolytes and water. Then it became a matter of how do we get this so that it can be used in the places that we were talking about?
DAVID NALIN: The last step of translation was going from intake and output in a study room where we had to sleep overnight next to the patients in case something went wrong. To teaching mothers. Making that methodology. Translating it into sunken eyes, tinted skin, more fluid, and-
RICHARD CASH: I should also note though, that David rightly has said, that the teaching mothers and so on. But who do you think was the greatest impediment? It was medical doctors, it was physicians, the MBBS’s who said this is too simple. We can’t do this. And we’ll probably get to. The place where the greatest problem was in a place like the United States where my god, how can you do something so simple when we can stick an IV in? And by the way, putting in an IV, and putting up somebody overnight, and so on. I don’t know. I’m not– I don’t-
DAVID NALIN: You’re not an accountant.
RICHARD CASH: Do the numbers. I’m not an accountant. But it’s thousands of dollars. As opposed to giving something to somebody early on in their illness, and having them rehydrate and then maintain. What is the price of that? That’s really nothing. So it’s always been disturbing to us is how far we as this highly advanced medical society are from this simple solution?
STEPHANIE FRIEDHOFF: So basically, you thought we have an idea, we think it’s going to work, we have this new part of how we’re going to do it.
DAVID NALIN: And then we wrote the protocol. And we carried it out.
RICHARD CASH: But there were people that precede us who saw oral as has the way. But the problem was is that for many of them, even though they did, they saw cholera which is what we were working on as almost too heroic. It was almost too heroic to give that amount of fluid. And so there was interest.
Physiologic studies had been done. But the important thing was to show that it worked clinically. And for that, there had to be a method of delivery, which then went from, as I said, the hospital with balanced studies. Us sleeping in the study room with our co-investigators. To then going out to a rural treatment center. And then going to the home. And even then, trying to adapt it to local beliefs and so on. And that’s again why it’s so important that it’s not just whether something works at the bench or in a highly sophisticated environment. It’s can you adapt it?
DAVID NALIN: Can you translate it?
RICHARD CASH: Can you translate to the situation?
DAVID NALIN: The intention.
RICHARD CASH: So there’s a lot that has to be done in any new technology of convincing the gatekeepers or others that this is something that’s actually good. It’s not second class. You don’t have to get an injection to do better. You can do it this way.
STEPHANIE FRIEDHOFF: It seems that you’ve spent a lot of your career trying to build that culture. What can we learn from why and how ORT has worked? And where should we look for other simple solutions?
RICHARD CASH: Well, I think that it’s a very interesting and a very important question because we know things. How do we do them? How do we take basic science? There were some physiology studies done here at Harvard that preceded us. But the link between what that meant and how it could be used wasn’t there.
I think that you in my experience in this area is that the translation and the [INAUDIBLE] gap take work. And they don’t happen overnight. It doesn’t quite work that way. You have to convince the gatekeepers whether they’re the doctors or the nurses in our case. Resistance can come from the community because they’ve also been told that this isn’t the right way to go. But at least my own experience is that if you are willing to put in the time and to convince others, and you have schools like this where you get to proselytize. And international groups, whether it’s WHO or some of these others.
DAVID NALIN: But it takes an army of workers because-
RICHARD CASH: It’s not one. And oftentimes, the people who do the basic science, are not always the best people to take it to the next level. It requires sometimes a different set of skills and so on. But we’ve seen things. Now, that said, it’s amazing how some things just haven’t been taken up. The cholera cot that I mentioned. The one cholera cot.
DAVID NALIN: And all the videos on the TV that you see about the Yemen cholera outbreak or the Haiti one, 99% of them have no cholera cot.
RICHARD CASH: Which are so inexpensive.
DAVID NALIN: What are the patients doing? They’re not measuring the losses.
STEPHANIE FRIEDHOFF: And why is that? If it’s so simple and it’s been used before.
RICHARD CASH: Because I think that there is a reluctance to go the simple way.
DAVID NALIN: Well, there’s a reluctance to take advice from people who are knowledgeable in the area. Each organization has its own hierarchy. I mean, it’s in the medical literature. It’s known for many experts. But still we see these organizations going in there and setting up treatment units. And they’re inappropriate. And they’re wrong. And they cannot succeed to the extent they would if they had the right equipment and advice.
RICHARD CASH: I’m very much for giving people the excuse of going over and experiencing the situation to see what in fact can happen. What in fact can take place. Neither one of us were in West Africa for the Ebola outbreak. But anecdotally, people have talked about how people were getting dehydrated and so on.
I have not seen any pictures from there where cholera cots were used. Though some people said that they were.
DAVID NALIN: With ebola, I think where back in 1830 because we haven’t done the basic science. And I’ve written about a letter that was published about this in the Journal of Tropical Medicine. No one has up until now taken a sample of Ebola diarrhea and found out what’s in it. How much salt are they losing? Preliminary data, what data that’s come out, there’s no measurement of that salt level. But preliminary blood tests show hyponatremia. Low sodium in the blood. Not normal or high.
So it raises the question, well, maybe they’re losing a lot more sodium than in cholera. But it says so-
DAVID NALIN: They we’re importing beds. Again, from the news stories from the US. They could have made these cots for 20 bucks apiece. $30 bucks apiece. I could show you. And I mean why? Why not? And I think that sometimes when you don’t have, then you create. And oftentimes, you create things that are better than if you brought them in, if you imported them, and so on.
And there’s also been a reluctance. Recently this has changed. But who are you going to take advice from? Doctors from Bangladesh? Or doctors from the Mass General?
DAVID NALIN: Or doctors from your local pediatric department, which is another phase.
RICHARD CASH: Yeah. So where are you going to do it? I’m not casting aspersions on anyone. I’m just simply saying that there seems to be a reluctance oftentimes to look for experience, and simplicity, and so on. Now, evidently, the cholera hospital where we work now when there’s a cholera outbreak, they send for them. But for years, and years, and years, nobody did.
STEPHANIE FRIEDHOFF: What is your advice to people entering the field today?
RICHARD CASH: Well, I mean people are coming in from all different angles. From program management to field research. There’s so many different things. I suppose the thing I tell the students more than anything is get out there and get experience. Don’t go in and start planning programs or doing model building. All this stuff.
First, get out and see what actually is going on out there. The more experience you can get in the field, the better it will serve you in the long run. Because otherwise, you’re going to be working with other people’s ideas and other people’s. Get out there and see what’s actually taking place. I just think that that’s– it certainly was critical to me, to David, and so on.
Even if you end up not doing global research, which most people won’t do. But the actual being out there, seeing what’s happening, collecting data in the field, seeing what the opportunities are and the limitations is very, very important. I can’t think of a better way to spend some time, whether it’s a few months or what have you. But don’t do global health from Boston never having actually seen the situation. To me, it makes no sense at all.
{***Noah***}
That was a conversation with Richard Cash and David Nalin about Oral Rehydration Therapy. Thank you for Stefani Friedhoff for recording and sharing that conversation.
If you’d like to learn more about ORT, we’ll have some information on our website, hsph.me/thisweekinhealth. We’ll also have a link to video of that event honoring Richard Cash we mentioned at the beginning of the episode.
And just a note that this is our last episode of 2018. We’ll be back in 2019 with all new episodes.
Thank you for listening—and happy new year!
December 19, 2018 — Oral rehydration solution (ORS)—a mixture of water, sugar, and salt that is administered as part of oral rehydration therapy (ORT)—is credited with preventing tens of millions of deaths from cholera and other diarrheal diseases. In this week’s podcast you’ll hear from two scientists who helped bring this simple, low-tech, and cost-effective treatment into worldwide use. Richard Cash, senior lecturer on global health at Harvard T.H. Chan School of Public Health, and David Nalin, professor emeritus at Albany Medical College, collaborated on groundbreaking clinical studies showing that ORT was remarkably effective in reversing dehydration.
This episode is a collaboration with Harvard Global Health Institute.
You can subscribe to Harvard Chan: This Week in Health by visiting iTunes or Google Play and you can listen to it by following us on Soundcloud, and stream it on the Stitcher app or on Spotify.
Learn more
A lifesaving therapy—and the researcher who helped launch it
Watch video of a recent event honoring Richard Cash