A Simple Solution

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Mahalanabis' gamble paid off. The fatality rate among the patients in the camp fell to 3% from 30%, and to less than 1% when IV fluids were administered to the most severely ill. Still, skepticism about the effectiveness of oral rehydration continued. Several journals refused to publish Mahalanabis' paper about the outbreak. But Dhiman Barua, then head of WHO's bacterial diseases unit in Geneva, Switzerland and a survivor of the massive 1932 cholera epidemic in Bangladesh's southern port city of Chittagong, had visited Mahalanabis' camp. He was converted and pushed oral rehydration through all the U.N. health agencies. who rolled out its diarrheal-diseases control program in 1978. "The simplicity and power of this tool gave it its own momentum," Mahalanabis says. Power indeed: the initiative cut total worldwide diarrhea deaths from about 5 million in 1980 to 3 million today.

In Bangladesh alone, child mortality fell from 35% to 6% over the following 20 years. But far too many people are still dying from preventable diarrheal diseases. Today, according to unicef, diarrhea still claims the lives of 36,000 young Bangladeshi children a year. Infants like Sohag would perish if they didn't live near a hospital — because they were born to parents unfamiliar with oral rehydration. For the third time in 12 days, 6-month-old Ullash has been admitted to the ICDDR's children's ward; just one of 325 patients admitted within the last 24 hours. The boy weighs only 69% of the expected weight for his age and is malnourished. He has a high fever, a cough and persistent diarrhea. His parents, Jurin and Nazdin, educated Dhaka residents, wait anxiously as he receives intravenous fluids. "We don't understand where this is coming from," says Nazdin. But Sack, the center's executive director, knows. Malnutrition and diarrhea go hand-in-hand, and in Bangladesh both are so widespread that not even middle-class children can escape their self-perpetuating cycle. "If you have a child that is malnourished and who then loses more weight through diarrhea, and tries to make it up, but never makes it up because he is weak and has another episode of diarrhea, then it doesn't matter how well-off the parents are," he says. "That is a child who is on the road to death."

ICDDR spends $20 million a year treating up to 150,000 patients, its budget financed mostly by grants from the government, international aid agencies and charities. At an average cost of $5 a day for each patient, the center stretches that money a long way. When the monsoon season begins, the hospital erects giant tents in its parking lot to cope with the extra patients. But the success of the hospital in Dhaka has not been replicated elsewhere.

In Africa, the fight against diarrhea is hampered by the lack of clean water and the infrastructure necessary to ensure public health. In countries like Ethiopia, only 40% of people have access to safe water, and fewer than 1 in 3 has regular access to safe sanitation, which at a minimum means a pit latrine. Most Ethiopians don't make the connection between the way they dispose of human waste and their family's health; instead, they believe that "diseases are transmitted by the will of God," says Worku Fentahun, head of health for the Banja district in the country's north. As a consequence, the average Ethiopian child suffers five to 12 episodes of diarrhea a year. Based on studies by the country's government and the World Bank, and by the Ethiopian Ministry of Health, between 50,000 and 112,000 Ethiopian children under 5 die from diarrhea every year. So for the past three years, unicef, the government, churches and ngos have led a campaign to teach Ethiopians the basic principles of hygiene, the importance of washing their hands and how to build their own toilets. The government has also trained health extension workers, mostly women, who can then teach other villagers about sanitation.