While hospitals in Dhaka ran through their last crates of intravenous fluid, a young American doctor was working a different problem. Not how to get more IV bags into East Pakistan, but how to make them unnecessary.
David Nalin arrived in Dhaka in 1967, fresh from his first year of medical residency at Montefiore Hospital in New York. He was posted to the Pakistan-SEATO Cholera Research Laboratory as a research associate for the National Institutes of Health.
The U.S. had a military draft, and many young doctors joined the Public Health Service instead. Nalin ended up in one of the most cholera-ravaged regions on earth.
Cholera kills by draining the body of water. A patient can lose liters of fluid in hours through diarrhea and vomiting.
Without rehydration, organs fail. The case fatality rate ran between 30 and 50 percent.
The standard treatment was intravenous therapy: sterile bags, needles, tubing, trained staff. In rural East Pakistan, those supplies ran out before the patients did.
Physiologists already knew that glucose and sodium are co-transported across the wall of the small intestine and that this mechanism stays intact during cholera. The gut can still absorb.
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The question was whether a patient could drink enough of the right oral solution, fast enough, to replace what cholera was taking out. The medical consensus said no.
In April 1968, Nalin tested a glucose-sodium oral solution on cholera patients at the Dhaka lab. The amount of intravenous fluid needed dropped by 80 percent.
Then came the harder test. Matlab, a treatment center downriver, had no electricity and limited medical supplies.
Nalin and his colleague Richard Cash treated 135 cholera patients there using oral rehydration therapy. It worked.
That was the decision that mattered. Not a dramatic rescue but a young doctor choosing to trust a simple formula against the weight of accepted practice, in a place where being wrong meant patients died on cots in front of him.
Three years later, the proof arrived at scale. During the Bangladesh Liberation War of 1971, ten million refugees crowded into camps in West Bengal, India.
Cholera swept through the camps. There were not enough IV supplies for a fraction of those infected.
Oral rehydration therapy was deployed. The cholera mortality rate dropped from roughly 30 percent to 3.6 percent.
The Lancet called oral rehydration therapy "potentially the most important medical advance of this century." A single packet of oral rehydration salts costs a few cents to produce.
It does not require a doctor. It does not require electricity or sterile equipment.
Nalin's discovery has been estimated to have saved over 50 million lives worldwide, according to a 2007 assessment published in the BMJ. He received the Pollin Prize for Pediatric Research in 2002 and the Prince Mahidol Award from the King of Thailand in 2007.
He never received a Nobel Prize.
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