Harvard Public Health Review Winter 2007
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Oral Rehydration Therapy

bangladeshi flood victim
TROUBLED WATERS Diarrheal diseases are rampant wherever humans encounter sewage-born pathogens, including deadly E. coli, rotavirus, and vibrio cholerae, the cholera bacterium. In Bangladesh, where 147 million people inhabit an area smaller than Iowa, many lack clean water.

'Rock star' in Dhaka
"Taking science to the people," as Cash puts it, is the operative word at BRAC University, in Dhaka, the Bangladeshi capital. In addition to collaborating with ICDDR,B researchers for 35 years, Cash has been an architect of the university's James P. Grant School of Public Health, one of only two in the country. Named in honor of the late UNICEF director, the new school saw its first 26 MPH students graduate in January of 2006. By design, many were admitted from developing countries--Tanzania, Uganda, Afghanistan, the Philippines, India, and Pakistan. Half were Bengali. Half were women.

Cash was the "obvious choice" to help lead the feasibility study for the school, says its international director, Demisse Habte. According to Habte, a former director of the ICDDR,B, Cash is "like a rock star" in the world of public health, adding, "To much of Asia, he is Harvard University."

Women in Dhaka are interviewed by students
REAL-WORLD LESSONS at the new James P. Grant School of Public Health in Bangladesh, students are immersed in field research. In this slum in the capital city, Dhaka, they interview women regarding health-seeking behaviors and other health practices.

To map out a curriculum, Cash sat down with BRAC's founder and president, Fazle Hasan Abed, and colleagues from Columbia University's Mailman School of Public Health, the London School of Tropical Diseases, and the University of Amsterdam. A priority, they agreed, was to teach problem-solving through field research. Instead of taking five classes a semester in nine months, Grant students tackle courses one by one, in three- or four-week modules over 11 months. This intensive format is "the only cost-effective way to do it," says the School's dean, Mustaque Chowdhury, a former BRAC research director and Bell Fellow at the Harvard Center for Population and Development Studies who has known Cash for more than 30 years. The fledgling school now borrows six of its eight faculty members from universities in England, Sweden, the Netherlands, and the United States. Cash teaches introduction to public health and infectious disease epidemiology at the Grant School during HSPH's Winter term and the summer.

"Richard's an awesome teacher," says one of only two Americans in the Grant School's class of 2007, Noah Levinson, speaking over an Internet connection from Dhaka. Having founded a small NGO, Calcutta Kids, in a sprawling city slum in West Bengal, India, Levinson says he "wanted to study public health in a setting like the one I'm working in. I couldn't do that in the U.S."

"Richard has a deep passion for Bangladesh--knows the culture, knows the people," Levinson adds. "He is highly respected there. When he talks, people listen."

With close ties to the ICDDR,B, the Grant School has the potential to become a research magnet. But the school must recruit a permanent, high-caliber faculty--a challenge, Cash says, since "to attract good people, you must create an exciting learning environment and pay them well." To recruit first-rate students, full scholarships are being offered to students in the first five years, thanks to support from BRAC, ICDDR,B, UNICEF, the James P. Grant Trust, and the Bill & Melinda Gates Foundation.

'We want to train leaders'
It took a deadly cyclone, massive flooding, and a concert organized by the late Beatle George Harrison, in 1971, to bring Bangladesh to the West's attention. As refugees returned home from India following the end of the War of Liberation, newscasts portrayed their newborn country as the epicenter of human misery. That image persists despite substantial progress in this struggling democracy toward the Millennium Development Goals, ambitious benchmarks that hold governments accountable for health and economic growth (see http://www.mdgbangla.org/index_en.html).

"I'm from India, and even I had the false impression, growing up, that Bangladesh was a miserable place," says HSPH master's degree candidate Hirshini Patel. But on a Winter-term trip planned last year by Cash, with stops at BRAC, ICDDR, B, and the Grant School, Patel says, "I was amazed at what I saw. The natural beauty was stunning, and the people were gracious and welcoming." And resourceful, she adds. There was vibrancy, optimism, and determination, despite the widespread poverty.
"In one very small village we all crowded around one man with TB. He showed us his skin lesions and answered our questions, which were pretty personal," Patel says. "But he was very open, genuinely interested in helping us learn."

Today one in four Bengalis live on less than $1 a day, on the margins of survival. Yet, according to a 2005 U.N. report, the country is making meaningful progress toward its Millennium targets. BRAC, founded in 1972, has played a pivotal role by economically empowering families, especially women. A major contribution of this NGO, one of the world's largest, is its support of primary education for girls. This, along with ORT and other investments in public health, have prompted declines in infant-mortality and fertility rates (now 56 infant deaths per 1,000 and 3.3 live births per woman, respectively).

As celebrated in October, when the Nobel Committee awarded its Peace Prize to the Grameen Bank and its founder, Muhammad Yunus, the country is the birthplace of microlending, through which loans as small as $10 enable even beggars to operate vegetable stands, sell crafts, and start other small businesses. According to the World Bank, Bangladesh has seen a rise in gross domestic product per capita in the last three years of 4.3 percent.

But big challenges remain. Diarrheal diseases persist for lack of clean water and sanitation. "Our maternal death rate is one of the highest in the world," laments Chowdhury. Arsenic poisons well water in thousands of villages, he says. And pneumonia is a major killer of children, owing to what he calls "our number one problem: a lack of trained professionals."

That's where Cash, and Harvard, can help--"by training some of our faculty, and sending more faculty here," Chowdhury says. "We want to train leaders."

Reciprocal discoveries
Research assistance, too, is what Harvard can offer. Cash's own studies focus on ethical issues in research in developing countries. Last summer, Cash led ethics workshops in Beijing, New Dehli, and Karachi. A book he'll soon publish presents dozens of real-life dilemmas. How do you get informed consent in a society in which individuals cede decision-making to village elders? Should studies relax stringent U.S. protocols where researchers in other countries deem them irrelevant? What happens when researchers in South Asia don't define plagiarism in the same way their American collaborators do? Is it reasonable, in a study of prostitutes' attitudes toward condom use in a country rife with HIV, to hire men to pose as clients?
The answers, Cash notes, again depend on local policies and cultural norms. For example, "the Terri Schiavo [right-to-life] case would never have happened in China," he points out. "There, patient welfare is a family matter, and the government has no role."

On both ethical and pragmatic grounds, Cash objects to Western nations that lead studies overseas, yet fail to adopt the results themselves. Ironically, he notes, ORT has never been widely used in the United States. For children there is Pedialyte, costing $6 a bottle. Adults are hospitalized and treated intravenously. Even now, several hundred elderly Americans die of dehydration each year, in part because people's awareness of thirst declines in old age. One U.S. company is refining ready-made ORS for the country's aging population.

Bringing health to the world's most vulnerable people is an uphill climb, but Cash draws inspiration from small victories and his curious, ambitious students. Let others retire. For his next project, he hopes to help plan curricula for new public health schools to be created, with an assist from Harvard, by the Public Health Foundation of India, an innovative partnership between India's private sector and the central government. As for teaching, Cash says, "I'll be doing that forever."

For a detailed account of the development of oral rehydration therapy by Richard Cash and others, see www.hsph.harvard.edu/review/summer_solution.shtml. To learn more about HSPH's research collaborations in the developing world, see https://webapps.sph.harvard.edu/cfdocs/worldmap/map.cfm.

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Karin Kiewra is the associate director of development communications at HSPH and editor of the Review.

Photograph: REUTERS-Jayanta Shaw

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