The Simple Cure
Dilip Mahalanabis popularized one of the great medical advances of the 20th century. Why did his death last month go mostly unmentioned?
Just a few days after I wrote up “The Forgotten Revolution”—decrying the fact that the triumphs of public health and medicine were largely ignored in high-school history classes—I saw a brief allusion on Twitter to the sad news that Dilip Mahalanabis had died. Mahalanabis was one of the key figures—arguably the key figure—behind Oral Rehydration Therapy, a revolutionary and surprisingly simple technique that has prevented millions of people, particularly children, from dying of diarrheal diseases like cholera over the past few decades. Since Mahalanabis first began advocating for its use in the early 1970s, it has become a core intervention in UNICEF’s program to ensure childhood survival in the global south, and it’s included on the World Health Organization’s List of Essential Medicines. The Lancet called ORT “potentially the most important medical advance of the 20th century.”
And yet despite this extraordinary history, as far as I can tell no mainstream American news outlet has even mentioned Mahalanabis’s death. The only obituaries I can find through Google News are in Indian newspapers. Once again, we have a strange bias in our culture that keeps us from celebrating and sharing stories about people who save hundreds of thousands—or even millions—of lives through their work in public health or medical science. I don’t mean this callously, but it is an undeniable fact that if you are interested in getting newspaper headlines, you are better off becoming a mass shooter than inventing a life-saving medical therapy.
I was lucky that I happened to catch that fleeting reference to Mahalanabis’s death on Twitter, but it jumped out at me immediately because I had written about ORT’s significance at length in Extra Life. It’s an important story—and not just as a reminder of how we chronically undervalue advances in medicine. I already knew about that strange bias in our culture when I sat down to research Mahalanabis’s life and work. (Countering that bias was the primary motivation behind the entire Extra Life project.) The investigation into ORT’s history ended up teaching me something about innovation itself, something I had previously neglected in books like Where Good Ideas Come From and How We Got To Now. What made ORT so powerful was not that it was a more sophisticated response to a health threat. In fact, it was ignored by many because it actually looked like a step backwards in complexity. But that simplicity turned out to be crucial to its success.
By at least the 1920s, it had become standard practice in Western hospitals to treat cholera and other diseases that involved catastrophic dehydration by hooking the patients up to an IV and administering fluids to them intravenously. But setting up an IV for patients and administering fluids was not a viable intervention during a cholera outbreak affecting hundreds of thousands of people in places like Mumbai or Lagos. Crowded into growing cities, lacking both modern sanitation systems and access to IV equipment, millions of people—most of them small children—died of cholera over the first six decades of the twentieth century.
But all that started to change in the 1970s, thanks to Dilip Mahalanabis. In 1971, the Bangladesh Liberation War sent a flood of refugees into India that swelled in cities like Bangaon and Kolkata, leading to terrible outbreaks of cholera in the refugee camps. As news of the crisis spread, Mahalanabis suspended his research program in a Kolkata hospital lab and immediately went to the front lines of the outbreak. He quickly realized that the existing IV protocols were not going to work. Only two members of his team were even trained to deliver IV fluids. Going against standard practice, he and his team abandoned the slow and technical IV approach, and instead delivered boiled water supplemented with a mix of sugar and salts directly to the patients. Under Mahalanabis’s supervision, more than three thousand patients in the refugee camps received ORT therapy. The strategy proved to be an astonishing success: mortality rates dropped by an order of magnitude, from 30 percent to 3 percent, all by using a vastly simpler method of treatment.
Inspired by the success, Mahalanabis demonstrated to field‑workers how easy it was for nonspecialists to administer the therapy themselves. “We prepared pamphlets describing how to mix salt and glucose and distributed them along the border,” he later recalled. “The information was also broadcast on a clandestine Bangladeshi radio station.”
Over time, the ORT approach was embraced by the Bangladeshi government, who concocted an ingenious “teach a man to fish” approach to making the therapy mainstream. I first read about this part of the history in a wonderful essay Atul Gawande wrote for the New Yorker many years ago. “Coaxing villagers to make the solution with their own hands and explain the messages in their own words, while a trainer observed and guided them, achieved far more than any public‑service ad or instructional video could have done,” Gawande wrote. “Over time, the changes could be sustained with television and radio, and the growth of demand led to the development of a robust market for manufactured oral rehydration salt packets.”
As it happens, we just published an interview with Gawande on the TED Interview podcast, and while we actually had our conversation in late August, well before Mahalanabis died, we talked a little about ORT and its lessons. “It really is one of the great medical advances of the 20th century,” Gawande says in the interview:
What’s not recognized is there is an equal need for innovation in not just the discovery that this kind of thing works, but then in delivering it and seeing it drive to scale. So today more than 50 years after its discovery, diarrheal Illness is still among the top three killers of children under the age of five and less than half of them get access to oral rehydration therapy. So a place like Bangladesh had found ways to scale it up to make it so that over 90% of children would end up getting that therapy. And they cut their death rates by 80%…
The lesson here—which is particularly central in matters of public health, but presumably applies in other fields as well—is that it’s not sufficient to evaluate potential innovations exclusively in terms of how well they solve the problem they’re addressing. It’s just as important to look at how easy it is to scale and replicate the innovation. Sometimes the best approach is to innovate by making the solution less technically advanced. The basic approach behind ORT had been understood scientifically for at least two decades before Mahalanabis went to the front lines. But as the medical historian Joshua Nalibow Ruxin observed in a fascinating study of ORT’s history, the approach was ignored because “intravenous therapy appeared more scientific; there was an apparatus, and the physician could have precise control over the intake of a patient. Oral therapy appeared primitive and less controlled.” As it turned out, that “primitive” quality was a feature not a bug. It meant that anyone could administer the therapy, not just specialists.
RIP Dilip Mahalanabis. You were a true hero—and deserve to be celebrated as one in death.
One related aside: in addition to the full conversation with Atul Gawande on the TED Interview podcast, there’s a new installment of How Ideas Happen available to paying subscribers where I talk to Atul about his own writing practice. It’s a pretty fascinating conversation; if you’ve read his book The Checklist Manifesto, you won’t be surprised that he has a very methodical—almost quantitative—approach to how he does his writing and thinking. This episode is part of a special double feature that includes the brilliant writer on health inequality Linda Villarosa as well, author of the new book Under The Skin. And I’ve just recorded a conversation that will drop in a few weeks with David Byrne about his own creative practice. You can get access to all these conversations just by upgrading to a paying subscription.
[The descriptions of Mahalanabis’s early work with ORT are adapted from a few passages in Extra Life.]