In 1968, The Lancet published the
results of a modest trial of what is now regarded as among the most important
medical advances of the twentieth century. It wasn’t a new drug or vaccine or
operation. It was basically a solution of sugar, salt, and water that you could
make in your kitchen. The researchers gave the solution to victims of a cholera
outbreak in Dhaka, the capital of what is now Bangladesh, and the results were
striking.
Cholera is a violent and deadly
diarrheal illness, caused by the bacterium Vibrio cholera, which the victim
usually ingests from contaminated water. The bacteria secrete a toxin that
triggers a rapid outpouring of fluid into the intestine. The body, which is
sixty per cent water, becomes like a sponge being wrung out. The fluid pouring
out is a cloudy white, likened to the runoff of washed rice. It produces
projectile vomiting and explosive diarrhea. Children can lose a third of their
body’s water in less than twenty-four hours, a fatal volume. Drinking water to
replace the fluid loss is ineffective, because the intestine won’t absorb it.
As a result, mortality commonly reached seventy per cent or higher. During the
nineteenth century, cholera pandemics killed millions across Asia, Europe,
Africa, and North America. The disease was dubbed the Blue Death because of the
cyanotic blue-gray color of the skin from extreme dehydration.
In 1906, a partially effective
treatment was found: intravenous fluid solutions reduced mortality to thirty
per cent. Prevention was the most effective approach. Modern sewage and water
treatment eliminated the disease in affluent countries. Globally, though,
millions of children continued to die from diarrheal illness each year. Even if
victims made it to a medical facility, the needles, plastic tubing, and litres
of intravenous fluid required for treatment were expensive, in short supply,
and dependent on medical workers who were themselves in short supply,
especially in outbreaks that often produced thousands of victims.
Then, in the nineteen-sixties,
scientists discovered that sugar helps the gut absorb fluid. Two American
researchers, David Nalin and Richard Cash, were in Dhaka during a cholera
outbreak. They decided to test the scientific findings, giving victims an oral
rehydration solution containing sugar as well as salt. Many people doubted that
victims could drink enough of it to restore their fluid losses, typically ten
to twenty litres a day. So the researchers confined the Dhaka trial to
twenty-nine patients. The subjects proved to have no trouble drinking enough to
reduce or even eliminate the need for intravenous fluids, and none of them
died.
Three years later, in 1971, an Indian
physician named Dilip Mahalanabis was directing medical assistance at a West
Bengal camp of three hundred and fifty thousand refugees from Bangladesh’s war
of independence when cholera struck. Intravenous-fluid supplies ran out.
Mahalanabis instructed his team to try the Dhaka solution. Just 3.6 per cent
died, an unprecedented reduction from the usual thirty per cent. The solution
was actually better than intravenous fluids. If cholera victims were alert,
able to drink, and supplied with enough of it, they could almost always save
their own lives.
One might have expected people to
clamor for the recipe after these results were publicized. Oral rehydration
solution seems like ether: a miraculous fix for a vivid, immediate, and
terrifying problem. But it wasn’t like ether (as first gas of anaesthesia) at all.
To understand why, you have to imagine
having a child throwing up and pouring out diarrhea like you’ve never seen
before. Making her drink seems only to provoke more vomiting. Chasing the
emesis and the diarrhea seems both torturous and futile. Many people’s natural
inclination is to not feed the child anything.
Furthermore, why believe that this particular mixture of sugar and salt would be any different from water or anything else you might have tried? And it is particular. Throw the salt concentration off by a couple of teaspoons and the electrolyte imbalance could be dangerous. The child must also keep drinking the stuff even after she feels better, for as long as the diarrhea lasts, which is up to five days. Nurses routinely got these steps wrong. Why would villagers do any better?
A decade after the landmark findings,
the idea remained stalled. Nothing much had changed. Diarrheal disease remained
the world’s biggest killer of children under the age of five.
In 1980, however, a Bangladeshi
nonprofit organization called BRAC –
Bangladesh Rural Advancement Committee - decided to try to get oral
rehydration therapy adopted nationwide. The campaign required reaching a mostly
illiterate population. The most recent public-health campaign—to teach family
planning—had been deeply unpopular. The messages the campaign needed to spread
were complicated.
Nonetheless, the campaign proved
remarkably successful. A gem of a book published in Bangladesh, “A Simple
Solution,” tells the story. The organization didn’t launch a mass-media
campaign—only twenty per cent of the population had a radio, after all. It
attacked the problem in a way that is routinely dismissed as impractical and
inefficient: by going door to door, person by person, and just talking.
It started with a pilot project that
set out to reach some sixty thousand women in six hundred villages. The
logistics were daunting. Who, for instance, would do the teaching? How were
those workers going to travel? How was their security to be assured? The brac
leaders planned the best they could and then made adjustments on the fly.
They recruited teams of fourteen young
women, a cook, and a male supervisor, figuring that the supervisor would
protect them from others as they travelled, and the women’s numbers would
protect them from the supervisor. They travelled on foot, pitched camp near
each village, fanned out door to door, and stayed until they had talked to
women in every hut. They worked long days, six days a week. Each night after
dinner, they held a meeting to discuss what went well and what didn’t and to
share ideas on how to do better. Leaders periodically debriefed them, as well.
The workers were only semi-literate,
but they helped distill their sales script into seven easy-to-remember
messages: for instance, severe diarrhea leads to death from dehydration; the
signs of dehydration include dry tongue, sunken eyes, thirst, severe weakness,
and reduced urination; the way to treat dehydration is to replace salt and
water lost from the body, starting with the very first loose stool; a
rehydration solution provides the most effective way to do this. brac’s
scientists had to figure out how the workers could teach the recipe for the
solution. Villagers had no precise measuring implements—spoons were locally
made in nonstandard sizes. The leaders considered issuing special measuring
spoons with the recipe on the handle. But these would be costly; most people
couldn’t read the recipe; and how were the spoons to be replaced when lost?
Eventually, the team hit upon using finger measures: a fistful of raw sugar
plus a three-finger pinch of salt mixed in half a “seer” of water—a pint
measure commonly used by villagers when buying milk and oil. Tests showed that
mothers could make this with sufficient accuracy.
Initially, the workers taught up to
twenty mothers per day. But monitors visiting the villages a few weeks later
found that the quality of teaching suffered on this larger scale, so the
workers were restricted to ten households a day. Then a new salary system was
devised to pay each worker according to how many of the messages the mothers
retained when the monitor followed up. The quality of teaching improved
substantially. The field workers soon realized that having the mothers make the
solution themselves was more effective than just showing them. The workers
began looking for diarrhea cases when they arrived in a village, and treating
them to show how effective and safe the remedy was. The scientists also
investigated various questions that came up, such as whether clean water was
required. (They found that, although boiled water was preferable, contaminated
water was better than nothing.)
Early signs were promising. Mothers
seemed to retain the key messages. Analysis of their sugar solutions showed
that three-quarters made them properly, and just four in a thousand had
potentially unsafe salt levels. So brac and the Bangladeshi government took the
program nationwide. They hired, trained, and deployed thousands of workers
region by region. The effort was, inevitably, imperfect. But, by going door to
door through more than seventy-five thousand villages, they showed twelve
million families how to save their children.
The program was stunningly successful.
Use of oral rehydration therapy skyrocketed. The knowledge became
self-propagating. The program had changed the norms.
Coaxing villagers to make the solution
with their own hands and explain the messages in their own words, while a
trainer observed and guided them, achieved far more than any public-service ad
or instructional video could have done. Over time, the changes could be
sustained with television and radio, and the growth of demand led to the
development of a robust market for manufactured oral rehydration salt packets.
Three decades later, national surveys have found that almost ninety per cent of
children with severe diarrhea were given the solution. Child deaths from
diarrhea plummeted more than eighty per cent between 1980 and 2005.
As other countries adopted Bangladesh’s
approach, global diarrheal deaths dropped from five million a year to two
million, despite a fifty-per-cent increase in the world’s population during the
past three decades. Nonetheless, only a third of children in the developing
world receive oral rehydration therapy. Many countries tried to implement at
arm’s length, going “low touch,” without sandals on the ground. As a recent
study by the Gates Foundation and the University of Washington has documented,
those countries have failed almost entirely. People talking to people is still
how the world’s standards change.
His
research work currently focusses on systems innovations to transform safety and
performance in surgery, childbirth, and care of the terminally ill. He serves
as the lead adviser for the World Health Organization’s Safe Surgery Saves
Lives program, and is the founder and chairman of Lifebox, an international
not-for-profit that implements systems and technologies to reduce surgical
deaths globally.)
