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Dispatches from the Field:

Jon E. Rohde

A Simple Solution

By Jon E. Rohde
Dhaka, Bangladesh

Spring 2005

When I stepped off the plane to the steamy hot monsoon air of Bangladesh some 37 years ago, I had little idea that I would remain so long! As a newly graduated doctor from Harvard I expected to serve a few years and return to Boston, but the challenges and opportunities proved so exciting, and the prospect of solving some of the most pressing human problems so rewarding that I have stayed working in poor countries to this day. No regrets!

Participating in the research that led to Oral Rehydration Therapy (ORT) brought Harvard science into the far-flung villages of the Ganges delta. This solution of several salts and glucose proved to save lives from the massive loss of fluids that characterize this most feared epidemic illness. While it worked in the hospitals, it took the huge refugee crisis of the 1972 Bangladesh liberation war, when cholera swept the crowded camps housing 10 million refugees, to show how robust this new technology is. Far from any hospital, we mixed large quantities of the correct ingredients and taught family members to administer a large glass of ORT each time the patient passed liquid stools — each movement out followed by an equal amount in! Some patients required 20 to 30 liters (quarts) per day, but the disease is self-limiting and in a few days they recovered. Mortality fell from over 30% of cases to under 3 %, even in such a primitive setting! Small wonder the Lancet editors described ORT as "potentially the most important medical advance of the 20th century".

While the refugees huddled in the mud and rain of the camps, the war raged inside Bangladesh, accompanied there too by cholera. Along with Bengali colleagues, I trained young volunteers to make ORT from packaged raw ingredients, using teaspoon measures and a standard sized glass, preparing them to return behind the lines and save lives as their positive contribution to the liberation war. This Volunteer Service Corps spread ORT to the farthest villages, saving lives and gaining confidence for the new nation.

While "modern hospitals" continued to treat diarrhea with costly intravenous fluids, ORT spread in rural clinics and soon into pharmacies in convenient foil packets that had all the correct ingredients in the proportions to make one liter. The World Health Organization (WHO) established a program to train doctors and nurses all over the world in the use of ORT and the United Nations Children's Fund (UNICEF) provided millions of ORT packets. By the late 1970s, oral treatment was the international norm. In fact, when I visited my alma mater in Boston, it was the only place I found still hospitalizing kids and rehydrating them with intravenous catheters — they too soon changed to ORT!

One day, seeing patients on the porch of a headman's house in a far rural village, a man was carried to me comatose, collapsed from severe cholera. No ORT packets were available — he was on the brink of death. I asked for water, salt and sugar. They brought me a clay pot and some dark molasses and crude sea salt — all they had. Guessing at the correct proportions I hastily mixed up a solution in the pot and started spooning it into the man's slack cheeks. He sputtered and swallowed, most of the fluid flowing out of his mouth and across his chest. Patiently persisting, I managed to get a liter or so into his stomach, and he started to come around, drinking with some new vigor. In an hour he was sitting up and departed in my jeep for the hospital some 25 kilometers away. When I arrived there in the evening, he was walking stiffly around the ward, continuing to drink ORT to replace ongoing losses. I was a convert to "simple solutions".

Subsequently, BRAC, the largest community NGO in Bangladesh, embarked on an ambitious program going house to house across the countryside teaching each and every mother how to make and use "home ORT" from molasses, salt and water. It took them over 10 years with some 2500 women trainers to reach every one of 13 million households and patiently teach each woman to make and administer the "simple solution". Dramatically, infant mortality fell by half over this time, and diarrhea, previously the number one cause of death became far less fatal. Today Bangladesh has the highest use rate of ORT in the world — it is part of the local culture.

Earlier this year I was in some of the villages I used to visit 30 years ago. They are still poor, and more crowded than ever, but the women are transformed from those I knew a generation ago. They look you in the face, tell with confidence how they feed and nurture their children. They vie with each other to show how to mix home ORT, as well as describe the benefits of breast milk, their preference for iodized salt, and can explain why they weigh their babies each month, right in the village to be sure they have adequate weight gain. Two thirds boast that they are using modern family planning methods, and insist that their kids, especially daughters stay in school. They enthusiastically show vegetable gardens, chickens and fish ponds that provide their family with quality food. It is a transformed population of empowered women, no longer passive and submissive, who have learned how to better control their own destiny and that of their family.

That seems a long way from Oral Rehydration Therapy, but it all started with the "simple solution" that saves lives.

About the author:

Dr. Rohde, a Harvard trained public health specialist and pediatrician, is an international public health consultant. For the past thirty-five years he has lived and worked in developing countries conducting research on diarrheal disease and nutrition in Bangladesh, representing the Rockefeller Foundation in Indonesia, and directing the Rural Health Delivery System for Haiti. The first Director of the EQUITY Project, he came to South Africa from twelve years in India where he was the Representative of UNICEF (1993-97) and the Global Advisor for health and nutrition to Mr James Grant during his 15-year tenure as Executive Director of UNICEF.

Mother and child, Bangledesh.

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