This Saturday marks the 40th anniversary of Bangladesh's war for independence from Pakistan. Given how bloody the war proved to be, and how limited development progress in the country has been since then, it might seem like a dubious occasion for those of us far from Dhaka to celebrate. But the war does have one unambiguously positive legacy: It gave the world an approach to dealing with cholera and other diarrheal diseases that has since saved many more lives than were lost during the fighting.
Cholera outbreaks have been a regular feature of urban living worldwide for centuries. The disease spreads through contaminated water and produces a toxin in the small intestine that leads to muscle spasms, abdominal pains, vomiting, and -- deadliest of all -- gushing diarrhea. This highly infectious liquid is the usual culprit in cholera outbreaks -- it contaminates water supplies, thereby reaching new hosts.
After a series of outbreaks in mid-19th century London took tens of thousands of lives, doctors and civic leaders pinned the blame, accurately, on the city's appallingly inadequate sanitation system. Writers at the time described huge piles of human and animal excrement collecting in the streets and fetid rivers almost solid with waste. The solution, devised by civil engineer Joseph Bazalgette and completed in 1865, was a network of five new sewer lines that transported waste out of the city. With that momentous project, London freed itself from major cholera outbreaks.
The problem, however, was that such solutions were expensive and complicated. Lacking the genius of Bazalgette and the wealth of empire, most of the rest of the world went on suffering from diarrheal disease without much respite well into the 20th century. But while it is still the case today that only half of the developing world's population has access to well-built latrines or septic and sewage systems, the death toll from waterborne disease has been dropping dramatically around the globe. And the gains against cholera and its relatives are mostly due not the model of Victorian England, but to the type of approaches pioneered in war-torn, poverty-stricken Bangladesh.
As troops loyal to West Pakistan fought Bengali paramilitaries and Indian troops over the course of 1971, 9 million refugees flooded across the border of what was then East Pakistan into India. At the time, Dr. Dilip Mahalanabis was working in a refugee camp in Bangaon, in India's state of West Bengal, home to more than 350,000 refugees. He faced an epidemic of diarrheal disease spreading death throughout the camp, with mortality rates among infected patients running as high as 20 to 30 percent. At the time, intravenous salt solution was the standard response to diarrheal dehydration. But Mahalanabis had only two aides capable of administering intravenous drips, and supplies were running out. Overwhelmed, he turned to what hospital workers considered a decidedly inferior approach to tackling dehydration: giving people sugar-salt solution to swallow, or oral rehydration.
We usually rehydrate orally: it is called drinking. Unlike intravenous drips, downing a glass of solution doesn't take skilled assistance -- it also tastes great to people who are dehydrated (though less so to the rest of us -- imagine drinking sweetened sea water). Mahalanabis just set up drums of the solution and told family members to keep on coming back with cups and bottles to fill until their relatives refused to drink more of the stuff. Rather than treating a few lucky victims who managed to make it to the clinic, the doctor was reaching people all across the camp. Death rates dropped from 20 to 30 percent to a stunning 3 percent.
Since 1971, and with the active support of the World Health Organization and donors, this type of oral rehydration has become a standard treatment for diarrheal disease. Sugar-salt packages mixed in the right proportions are now widely available for a few cents a dose, and even cheaper tools of prevention are available. There are bottles designed to use sunlight to disinfect water; programs encouraging people to add a small amount of bleach to drinking water have reduced diarrhea cases by between 50 and 80 percent.