The Civil War That Killed Cholera

Why the best ideas for fighting some diseases may come from poor countries, not rich ones.

BY CHARLES KENNY | MARCH 21, 2011

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.

FARJANA K. GODHULY/AFP/Getty Images

 

Charles Kenny is a senior fellow at the Center for Global Development, a Schwartz fellow at the New America Foundation, and author, most recently, of Getting Better: Why Global Development Is Succeeding and How We Can Improve the World Even More. "The Optimist," his column for ForeignPolicy.com, runs weekly.

PROJWAL

4:33 PM ET

April 14, 2011

ORS is certainly a great

ORS is certainly a great check against water borne diseases, but one must realize that this is a cure or a treatment for such health problems and it deals with the harmful outcome of poor sanitation, the cause of such diseases. Effective healthcare requires proper sanitation. Wouldn't it be better if people were not subjected to an unhealthy environment in the first place rather than frequently using medicines because they experience these diseases many times as a result of that environment? And creating proper sanitation in rural areas need not be a difficult and expensive task, as they are not situated in densely packed urban areas that have to take into consideration the quantity and variety of sewage to be dealt with and the limited space available in these areas. As far as the urban areas go, one of the reasons for the objections raised against Bazalgette's plan is that such a project requires the availability of "an empire of wealth", is plentily available in developed nations but lacking in the developing world. It should know that aid agencies and international financial institutions involved in development have the resources to finance such projects.

Of course, in many developing nations, especially in Sub-Saharan Africa, such plans may not be implemented for decades to come because of poor governance and the lack of proper institutions. ORS shall remain an effective health care measure for decades to come, and therefore, I agree with you, that till proper governance happens, ambitious projects cannot work.

 

MARKMIGNET

9:58 PM ET

April 18, 2011

Water and War?

Came across this today after I found this wonderful site. And having enough impact of Bangladesh breakup in my life, could not help but read this article. Alas, my grandma who passed away 20 days back had borne the impacts of this war so badly that she would have survived a few more years had this war not happened. The immense had broken her health. So stunned to come across such an article while I am still mourning and crying (crying is not manly - its more like a bv lady, but that's real life for you).

I had no idea that something as simple as a packed salt water pouch can help in situations as grave as Cholera. The title of this article is so similar to Love in the time of Cholera by the famous writer Gabriel Garcia Marquez and the content is so radically different from that, that one gets a weird feeling of the mix. Add personal history like I have here, and the whole story touches me to a depth that is almost unfathomable.

Surprised to see this article getting written on 21st March rather than 21st February - the day when Bangladesh announced independence. Wonder whether that date - 21 - is a coincidence or what...