Oral Rehydration Therapy - History

History

Prescriptions from the ancient Indian physician Sushruta date back over 2500 years with treatment of acute diarrhea with rice water, coconut juice, and carrot soup. However, this knowledge did not carry over to the Western world, as dehydration was found to be the major cause of death secondary to the 1829 cholera pandemic in Russia and Western Europe. In 1831, William Brooke O'Shaughnessy noted the loss of water and salt in the stool of cholera patients and prescribed intravenous fluid therapy (IV) to compensate. The results were remarkable, as patients who were on the brink of death from dehydration recovered. The mortality rate of cholera dropped from 70 percent to 40 percent with the use of hypertonic IV solutions. IV fluid replacement became entrenched as the standard of care for moderate/severe dehydration for over a hundred years. ORT replaced it with the support of several independent key advocates that ultimately convinced the medical community of the efficacy of ORT.

In the late 1950s, ORT was prescribed by Dr. Hemendra Nath Chatterjee in India for patients diagnosed with cholera. Although his findings predate physiological studies, his results failed to gain credibility and recognition because they did not provide scientific controls and detailed analysis. Credit for discovery that in the presence of glucose, sodium and chloride became absorbable during diarrhea (in cholera patients) is typically ascribed to Dr. Robert A. Phillips. However, early attempts to translate this observation into an effective oral rehydration solution failed, due to incorrect solution formula and inadequate methodology.

In the early 1960s, biochemist Robert K. Crane discovered the sodium-glucose cotransport as the mechanism for intestinal glucose absorption. Around the same time, others showed that the intestinal mucosa was not disrupted in cholera, as previously thought. These findings were confirmed in human experiments, where it was first shown that a glucose-saline oral therapy solution administered in quantities matching measured diarrhea volumes was effective in significantly decreasing the necessity for IV fluids by 80 percent. These results helped establish the physiological basis for the use of ORT in clinical medicine.

The events surrounding the Bangladesh Liberation War in 1971 convinced the world of the effectiveness of ORT. As medical teams ran out of intravenous fluids to treat the spreading cholera epidemic, Dr. Dilip Mahalanabis instructed his staff to distribute oral rehydration salts (ORS) to the 350,000 people in refugee camps. Over 3,000 patients with cholera were treated, and the death rate was only 3.6 percent, compared with the typical 30 percent seen in intravenous fluid therapy. The fact that ORT was delivered primarily by family members instead of trained staff across such a large population in an emergency fashion was demonstrative proof of the utility of ORT against cholera.

Between 1980 and 2006, ORT decreased the number of deaths that occurred worldwide from 5 million a year to 3 million a year. Death from diarrhea was the leading cause of infant mortality in the developing world until ORT was introduced. It is now the second leading cause of mortality for children under five, accounting for 17 percent of all deaths, second only to pneumonia, at 19 percent. Its remarkable success has led to naming the discovery of its underlying physiological basis as "potentially the most important medical advance century." ORT is part of UNICEF's GOBI program, a low cost program to increase child survival in developing countries, including growth monitoring, ORT, breastfeeding, and immunization. Despite the success and effectiveness of ORT, its uptake has recently slowed and even reversed in some developing countries. This raises concerns for increased mortality from diarrhea and highlights the need for effective community-level behavioral change and global funding and policy.

The individuals and organizations involved in the development of ORT have been recognized widely. The 2001 Gates Award for Global Health was awarded to the Centre for Health and Population Research, located in Dhaka, Bangladesh, for its role in the development of ORT. In 2002, the first Pollin Prize for Pediatric Research was awarded to Dr. Norbert Hirschhorn, Dr. Dilip Mahalanabis, Dr. David Nalin, and Dr. Nathaniel F. Pierce for their contributions in the discovery and implementation of ORT. For promoting the use of ORT, the 2006 Prince Mahidol Award was awarded to Dr. Richard A. Cash of Harvard School of Public Health, Dr. David Nalin, and Dr. Dilip Mahalanabis in the field of public health; and to Dr. Stanley G Schultz in the field of medicine.