Context

• In the demise of Dilip Mahalabnis on October 16 we lost a pioneering public health physician the ORS pioneer who helped save millions of lives. In 1978, a Lancet editorial termed ORS the most important medical advance in this century.

Background

• ORT was first introduced worldwide in the 1970s to treat millions of children suffering from severe dehydration in crisis-stricken and impoverished areas. At the time, the world’s leading general medical journal The Lancet called ORT “potentially the most important medical advance since penicillin.”
• A Lancet editorial in 1978 termed it “potentially the most important medical advance this century”.

Interesting story of Dilip Mahalabnis and invention of ORT

• Mahalanabis was trained as a paediatrician and joined the Cholera Research Programme of the Johns Hopkins University Center for Medical Research and Training (JHCMRT) in Calcutta in 1966.
• His team was treating cases of the cholera epidemic in a camp in Bangaon, West Bengal that housed 3,50,000 refugees but ran out of intravenous fluids. He thought that it would be opportune to use ORS. As no ORS packets were available, they mixed salt and sugar solution (ORS) in drums and administered it to the cholera patients in the camps.
• The library of the JHCMRT was converted into a factory. This was not a mandated mode of treatment and at great personal risk, Mahalanabis chose to respond to the humanitarian crisis in this manner.
• It was evident in two to three weeks’ time that not only was the therapy working but that it was possible to administer ORT through volunteers (in the absence of a sufficient number of trained workers).
• It was subsequently analyzed that ORS reduced mortality due to cholera or acute diarrhoeal diseases in these camps from 40 per cent to 5 per cent. They coined the term “oral saline” and rest is the story.

What is Oral Rehydration Therapy (ORT)?

• A fluid to correct dehydration: Oral Rehydration Therapy (ORT) entails drinking water with modest amounts of sugar and salts, specifically sodium and potassium to correct dehydration due to fluid losses from diarrhoea.
• ORT ingredients: ORT combines three ingredients such as salts, sugars and water to quickly reverse the signs of dehydration. Through the process of osmosis, the salts and sugars pull water into your bloodstream and speed up rehydration.
• Essential electrolytes which replenish Blood: ORT also replenishes your blood with essential electrolytes (minerals) that are lost due to intense exercise, exposure to extreme weather conditions, or diarrhea and other illnesses. Water doesn’t contain electrolytes and so, ironically, water alone cannot cure dehydration like ORT.
• An effective electrolyte: Administration of fluids through the intravenous route used to be the mainstay of management of cholera till the results of a study demonstrated that an oral solution of glucose and electrolytes was effective for replacing water and electrolyte losses.
• Quick and efficient: The translation of the basic science concept to quick and efficient practice was, however, not easy. And that is the fascinating story and sterling contribution of Mahalanabis and his co-workers on ORT.

What is Dehydration?

• Dehydration occurs when you use or lose more fluid than you take in, and your body doesn’t have enough water and other fluids to carry out its normal functions. If you don’t replace lost fluids, you will get dehydrated.

What is Disease Cholera?

• Cholera is an acute diarrhoeal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae that can kill within hours if left untreated.
• Most of those infected will have no or mild symptoms and can be successfully treated with oral rehydration solution. Cholera affects both children and adults.
• Provision of safe water and sanitation is critical to prevent and control the transmission of cholera and other waterborne diseases.
• Cholera remains a global threat to public health and an indicator of inequity and lack of social development.

Recent outbreak of cholera In India

• Cholera is said to be endemic in India. However, the reported cases in India tend to be much lesser than the actual numbers, say doctors and experts.
• The number of cases is rising in India because we still lack the basic sanitation, hygiene and access to clean water in many communities,
• The country reports nearly 20,000 to 30,000 cases of cholera every year, usually during the monsoon season of July to September.
• Climate change adds up another layer to the cholera outbreak.

Contribution of ORT to the world.

• As a perfect alternative over the prevailing doctrine: ORT was in marked contrast to the then prevailing doctrine of patients being given only sips of water without food, euphemistically called “resting the stomach”, often worsening the underlying malnutrition.
• For Diarrhoea: An estimated 54 million diarrhoeal deaths were averted by ORT alone between 1978 and 2008, such was the magnitude of its beneficial impacts. ORT for the management of severe diarrhea was developed in the latter half 1960s. WHO launched a worldwide campaign in 1978 to reduce mortality related to diarrhea, with ORT as one of the key elements.
• For cholera: Administration of fluids through the intravenous route used to be the mainstay of management of cholera till the results of a study demonstrated that an oral solution of glucose and electrolytes was effective for replacing water and electrolyte losses
• Cholera pandemic: This period coincided with the seventh cholera pandemic (El Tor biotype) that started in Indonesia in 1961 and spread to East Pakistan (Bangladesh) by 1963 and to India in 1964. Though experiments with ORS were underway, the WHO responded in 1970 by distributing large amounts of intravenous fluids – a move marked by high transportation costs and limited utilization on account of a shortage of a trained health workforce. The focus of the Southeast Asia Treaty Organization (SEATO), through the Cholera Research Laboratory in Dhaka, was to find a vaccine to protect the US troops from cholera attacks in Southeast Asia.
• One solution for everyone: Athletes; people with illnesses, especially babies and toddlers; seniors; military personnel stationed in extreme climates; air travelers who lose electrolytes every time they fly: They all stand to dramatically improve their health and well-being with ORT.

Conclusion

• Dilip Mahalanabis pioneered a simple and effective solution for diarrhoea that saves millions of lives which can be considered as one of the greatest contributions of Indian in medical sciences. To carry the carry legacy forward young scientists should step in.

Mains Question

Q. What do you Understand by Oral Rehydration Therapy? How it could be effective in tackling the yearly outbreaks of Cholera in India and the world. Discuss.

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