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Conquering cholera: A silent golden jubilee

Shihab Sarkar | May 18, 2018 00:00:00

That Bangladesh, previously East Pakistan, would one day find itself among the nations credited with overpowering a killer disease was unthinkable five decades ago. But the country could achieve the distinction by offering the world a simple, home-grown cure for acute diarrhoeal disease, a euphemism for cholera. Prior to the 1960s, classical cholera had been synonymous with painful deaths caused by a short but severe spell of dehydration. Its outbreak would normally hit the proportions of epidemic. In 2018 Bangladesh has potent reasons to celebrate the 50th anniversary of a breakthrough invention in 1968 which has saved over fifty million lives around the globe in the later decades. In the 21st century, lives of people in dozens of previously cholera-prone regions across the world can be saved by treating the disease with oral rehydration salt (ORS). Bangladesh has been made free of the incidence of cases of deaths from acute diarrhoeal disease. Its outbreak in epidemic forms has successfully been tackled in the last five decades. Thanks to the activities of SEATO Cholera Research Laboratory, later Cholera Hospital, now International Centre for Diarrhoeal Disease Research Bangladesh (ICDDR B), Dhaka can lay claim to a rightful distinction: the contribution of the international and local scientistists based in the city to the invention of a nearly magic cure for the disease. The initial curtain on the glorious chapter opened in the early 1960s.

Devising the amazing formula of oral rehydration salt (ORS) brought Dhaka in global spotlight in 1968. The plainness of the cure was unbelievable. It involved half litre water, a fistful of sugar or molasses and a pinch of salt. It was a team of indomitable American and Bengalee scientists who finally invented the easy cholera cure. Eventually, the invention proved a watershed, ensuring succour for millions of people at risk of being killed by diarrhoeal diseases --- mainly in the tropical regions.

In spite of water being the major cause of diarrhoeal diseases, it was also a potent treatment for cholera and similar ailments in early Bengal. The mention of cholera is found in ancient Sanskrit texts. Its prevalence is traced back to 1000 AD in eastern India. In Bengal, a common treatment for cholera comprised water soaked with flattened rice, locally called 'chirra'. Another cure was the paste of a certain type of green banana, normally eaten after cooking. The soaked 'chirra' and the banana paste is still used in remote Bangladesh villages. Many local people view the soaked 'chirra', containing carbohydrate and water, as the Rosetta stone which may have prompted the triumphant search for an effective cure for the deadly intestinal disorder. In fact, the invention of water-based ORS is inextricably linked to water; its later version, the rice-ORS, is based on rice powder and water.

The landmark created by ORS has a background filled with long patience and perseverance. As cholera causes severe dehydration to patients, teams of scientists back in 1964 in Manila, Dhaka and Chittagong got engaged in finding a remedy to it. But their efforts could not see much progress. They, however, did not feel discouraged. The following phase of the efforts to invent a cure opened at ICDDR B, then Cholera Research Laboratory, in Dhaka in 1967-68. After preliminary work, the scientists at the laboratory swung into full-scale field-level research at Dhaka and Matlab in Chandpur district, then in greater Cumilla. They were specially trying to prove the efficacy of the initial forms of ORS. Two young US scientists --- Dr David R Nalin (b 1941) and Dr Richard A. Cash (b 1941), then both 26 years old, led the whole team and campaign. Rafiqul Islam and Majid Molla, two scientists from Dhaka, also comprised the team. In an effort to tell the world about their research, the scientists chose 'Lancet', an authoritative medical journal published in the UK. In the August 1968 issue of the journal, the two Americans wrote how a combination of glucose, sodium chloride, sodium bicarbonate and potassium chloride could help stop the draining out of liquid from cholera patients. In the essay they highlighted the case for Oral Rehydration Therapy (ORT), which was accessible to even the rural poor. Thus the years-long run-up to the revolution saw its successful completion. In the following years, the use of oral rehydration began to be in place in Bangladesh and all cholera-endemic regions across the world. The American scientists carved out their place as two pioneering figures in world medical science. And Dhaka registered a position in the annals of places witnessing great events related to the welfare of mankind.

Thanks to its almost successful control in Bangladesh, the disease of classical cholera and its ravages are nearly unknown to the younger generations. Many of them cannot even imagine the extent of panic which would be created by cholera outbreaks in a region in the past. A highly contagious disease, cholera led to scores of otherwise preventable deaths in Bangladesh and its neighbouring countries. Once upon a time it would descend on large swathes of areas to eventually take an epidemic form. Concentrated mainly in the rural areas, the water-borne disease used to wipe out village after village. Like with the dreadful European Plague, the disease in course of time gave birth to a number of folk beliefs and popular tales. Those dealt with imaginary episodes like the trail of devastation left by a female evil force called 'Ola'. That the outbreaks of cholera were chiefly caused by unsafe water and stale food remained beyond the knowledge of the illiterate village folks. Those days are gone for good. Buying small packets of prepared ORS at pharmacies and big and small groceries is a common spectacle across Bangladesh. After the eradication of smallpox, another much-dreaded epidemical disease, people in the country had been grappling with the scourge of cholera. With the weakening of the ferocity of the diarrhoeal disease, the country is no longer battered by seasonal deadly diseases.

The cholera times normally make their onset during the Bengal summer, continuing up to its monsoon. These days, sporadic outbreaks of the disease are also seen in the urban areas and on their outskirts including those in Dhaka. As the ICDDR B headquarters are located in the capital, patients in the greater Dhaka region receive faster treatment compared to the remote areas. On the other hand, diarrhoeal disease patients in the distant areas largely remain deprived of effective treatment. It's true the nominally priced ORS packets are now available throughout Bangladesh. They provide a great therapeutic backup to the patients in distant areas of the country. But serious patients sometimes need a well-equipped and specialised 'hospital' such as the Dhaka ICDDR B. Coming to Dhaka from the distant parts in northern, northeastern and southwestern regions to seek treatment turns out to be arduous and expensive. Regional centres of the hospital can play a critical role in allaying the sufferings of the patients and attendants.

When it comes to the eradication of epidemical, as well as endemic, diseases, Bangladesh does not lag much behind many fast developing countries. With smallpox and classical cholera gone, and malaria subdued considerably, it is dengue, chikungunya, bird flu etc which are feared to afflict the nation in the future. However, the great strides made in detracting from the fierceness of the killer disease of cholera make the episode an achievement of monumental proportions. Thanks to the relentless efforts of ICDDR B and its scientists, the poor patients of Bangladesh could be spared the often complex and expensive treatment for the disease. That the cheap ORS and its handy process of preparation would receive a global acceptance was, in a way, a foregone conclusion during its very trial phase.

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