The Miracle of Salt and Sugar
Memories of Oral Rehydration Therapy – ORT
In 1968 Nalin and Cash demonstrated that oral rehydration could replace intravenous fluids in over 90% of cholera cases. The then director of the Cholera Lab (CRL) in Dacca, Dr. Robert Phillips decreed that no more research was needed, “It is now up to doctors to promote and use it”. The young investigators defied the order and clandestinely took ORS to the far-off rural hospital in Matlab which experienced a huge onslaught of cholera that year, which would have surpassed the supply of intravenous fluids several times over leaving patients to die. ORS saved the day and nearly all lives of hundreds of patients. Soon after, during the Bangladesh liberation war in 1971 cholera swept through the refugee camps around Calcutta. Dilip Mahalanabis treated hundreds showing that cholera cots and IVs were not essential if a family member gave the patient a full glass of ORS every time liquid stool was passed; mortality fell from 30% to 3%. Having worked at CRL and later in the refugee camps I joined Dilip to teach scores of patriotic young men how to make ORS from raw ingredients and they went behind the battle lines to promote its use to “liberate Bangladesh from cholera and from Pakistan”. A daily radio show from Calcutta beamed into the war-torn area promoted the making of the ORS formula, and “Oral Saline” became the popular treatment. UNICEF in Calcutta supported the training on ORS and provided needed supplies and soon began producing liter packets of ORS by local pharmaceutical firms.
The war won, FH Abed of BRAC decided to teach a mother in each and every hut in Bangladesh how to make and use ORT from local materials: molasses, salt and water. It took 10 years to reach 13 million households with one-on-one teaching with diarrhea deaths dropping from the top cause of child deaths in 1972 to 6th cause a decade later as IMR dropped from 140 to 38. Bangladesh has the highest use of ORT of any country in the world today.
Witnessing this, Jim Grant realized that ORT offered the most dramatic fall in child deaths of any intervention, leading to his “packet in the pocket” that he pulled out at every opportunity at state dinners and in meetings with presidents and kings, citing it as the cure for each country’s top cause of death which he enumerated in morbid detail. It was the centerpiece of his GOBI initiative though later he realized that UCI could also strengthen the peripheral health system while saving lives. More than that, Grant recognized that the entire thrust to “reach health for all'' had to start with a few steps that truly reached ALL and to build from there incrementally and over time to the full range of primary health care interventions. This was his true genius, to choose something impactful, yet simplified enough to reach into every village and every home, emphasizing good management, convincing communication and empowering of users who became implementers of his Child Survival and Development Revolution - CSDR. ORT was simply his “Trojan Horse '' the foot in the door of primary health care for everyone that would lead inevitably to an equitable and impactful healthy world for children.
Oral rehydration has saved tens of millions of lives over the past 50 years. In addition to diarrhea of all etiologies, it has been shown to treat dengue shock syndrome, heat exhaustion and sun stroke, and most recently Ebola, all of which kill by dehydration. Now, in the time of Covid 19 while many seek the magic bullets of miracle drugs, the simple expedient of masks, distancing and living out-of-doors can avoid millions of infections but a champion of these essential “doable” measures has not emerged. No doubt, Covid vaccines join with those of the EPI as miracles of our age, but even there, vast numbers are still in denial and supplies are terribly inequitable. It is time for a truly Universal Immunization Campaign. The lessons of CSDR and Jim Grant are alive as ever. Let us hope UNICEF and all other agencies pick up the challenge that Grant would have us rise to and reach into every hut with his message.
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